Insomnia and nerve strain

THE LIBRARY

OF

THE UNIVERSITY
OF CALIFORNIA

LOS ANGELES

Insomnia and Nerve Strain

By
Henry S. Upson, M.D.

Professor of Diseases of the Nervous System in the Western Reserve
University, Attending Neurologist to the Lakeside
Hospital, Cleveland, Ohio

/ &&&>$
With Skiagraphic Illustrations

G. P. Putnam's Sons

New York and London

Gbe "Knickerbocker press

1908

COPYRIGHT, 1908

. BY

HENRY S. UPSON

•Cbe Knicfcerbocher press, "Hew

r

A truth — four columns tottering,
The more with each successive brick, until
The key is added, then, foursquare and strong,
The world may rest on it.

iii

PREFACE

A MONO the insanities some groups due
** to changes in the organ of the mind
are understood in course and nature.
Others, called psychoses, aberrations that
come alike to young and old, mysterious
legacies, have all the terrors that attach
to mystery and occur in forms of strange
and violent contrast. Their ultimate
cause is unknown; they are precipitated
by physical and mental shocks and in-
juries varied in circumstance and fantas-
tic and deplorable in their effects. Why
these several causes should have one
result, and results at times so varied be
capable of springing from one cause is
a question whose solution might carry
with it chances of prevention and cure.

The test of a theory is its ability to
explain observed facts. To fully prove a
hypothesis all useful observations should
be made and sifted, including those facts

vi Preface

not previously observed because too
familiar. The mass of these at times
outweighs the other. An adequate the-
ory should explain the origin of psychoses
in these diverse and distant ways, make
of the fantastic deeds and mad fancies
of these unfortunates simple reactions
to causes such as influence the lives of
other men, and render definite the nature
of such an undesirable heritage and the
way of its transmission.

The present record was at first intended
as in the main a contribution to observed
facts. Circumstances have made of it
an attempt at an interpretation of more
familiar facts of wider range, with a few
observations in the part of the field which
happened at the time to be more nearly
in the author's view.

It is useless to cherish illusions with re-
gard to the present attitude of the med-
ical profession and the public toward
the psychoses. It is almost Mahometan
fatalism. The neuroses are often curable
by mental measures, the domination of
the body by the mind, but even medieval

Preface vii

sages and astrologers wasted few formu-
las over cases of insanity. The psycho-
ses are a stone wall against which the
waves of psychotherapy beat in vain.
At most they wear away a little of the
soft porous rock of the mildest of them.
Hence the deplorable fact that so soon
as a case is diagnosed as mania, melan-
cholia or dementia precox, the patient
is housed in an asylum, or at the very
best, fed and tended by some loving rela-
tive, pending the execution of nature's
sentence.

The doom of the patient lies inherent
in the definition of his malady. So
long as a psychosis is to the physician
a disease without a lesion, sufferers from
that dread malady offline soul will be
given care with practically no treatment,
pity with practically no hope.

No apology, then, is necessary for any
attempt to look behind the veil. It hides
disease so hopeless that from the more
dread form, dementia, fewer of those
afflicted recover, in spite of all that love
and skill can do, than of sufferers from

viii Preface

consumption or cancer or the black
plague itself. Those who do not recover
are found in our asylums, largely peopled
with these unfortunates.

No attempt is made in this small work
to collocate the material available for a
study of the psychoses. Two objects only
have been kept in view; to put on record a
few observations as material for the recon-
struction of a column long since fallen and
neglected by recent workers in this field,
and in what measure may now be feasible
to supply that most solid of all building
materials, a working theory to bind the
swaying fabric of the structure.

CONTENTS

PAGE

PRELIMINARY ..... i
ILLUSTRATIVE CASES . . . .12

SLEEP AND FATIGUE .... 44

THE EMOTIONS ..... 48

SUBCONSCIOUS SENSORY REFLEXES . . 57

ATAVISTIC SYMPTOMS .... 63

DERANGEMENTS OP FORMAL THOUGHT . 66

INDUCTIVE INHIBITION .... 70

CONVULSIVE SEIZURES AND CHOREIC

SPASM ...... 72

VASCULAR POTENTIAL .... 84

MECHANISM OF THE VASO-NEURAL

CIRCUIT ..... 94

NUTRITION AND VITALITY ... 98
CELL POTENTIAL IN EVOLUTION . .102

EPICRITICJsfBURO-PsYCHOSES . . 10$

x Contents

PACK

PROGNOSIS m

THERAPY . . . . . 114

PREDISPOSITION AND HEREDITY . . 125

APPENDIX:

DENTAL LESIONS .... 131

TECHNIQUE OF DENTAL SKIAGRAPHY 139

ILLUSTRATIONS

FACING
PACK

CASE 5. — Melancholia. Impacted upper left
third molar . . . . .14

CASE 14. — Hysteria. Impacted lower left
third molar . . . ... 14

CASE 15. — Acute Mania. Impacted cuspid
tooth . . . . . .14

CASE 1 6. — Incipient Dementia Precox. Im-
paction of all of the wisdom teeth . 14

CASE 1 8. — Dementia precox. Impaction of
a lateral incisor and all four wisdom teeth 38

CASE 1 8. — Dementia precox. Upper right
third molar . . . . 38

CASE 22. — Mania. Impacted lower third
molar ...... 38

xi

xii Illustrations

FACING
PACK

Case of profound melancholia, with subcon-
scious sensory reflex in upper incisor teeth.
Impaction of upper third molar. 38

Impacted upper fourth molar tooth . .38

CASE 2. — Insomnia. Alveolar abscess. Lower
molar tooth. Roots partly absorbed . 132

CASE 3. — Renal and Vascular Disease. Mul-
tiple abscesses in both upper and lower
jaws . . . . . . 132

CASE 4. — Melancholy. Alveolar abscess.
Molar tooth. Roots partly absorbed . 132

Case of Albuminuria with cardiac and vas-
cular symptoms. Complete nervous break-
down of five years' standing. Multiple
abscesses in both upper and lower jaws . 132

Position for upper right molar region. Tube
and film should be placed well back. (Dr.
Lodge.) ...... 142

(First.)

Position for lower right molar region. (Dr.
Lodge.) ...... 142

(Second.)

Illustrations xiii

FACING

PACK

Position for upper incisors. (Dr. Lodge.) 142
(Third.)

Position for lower incisors. (Dr. Lodge.) 142
(Fourth.)

INSOMNIA
AND NERVE STRAIN

\\ HTH regard to the nature of the
pathologic processes underlying
painful and other functional nervous and
mental disorders, authorities are at the
present day practically unanimous in as-
cribing them either to those most misty
of all indefinite conditions, nervousness,
hysteria, and autosuggestion, or to toxins
of unknown origin and uncertain nature.

PHYSICAL CAUSES OF INSANITY.—
Among the physical causes of insanity
diseases of viscera other than the brain
formerly held a prominent place, the

2 Insomnia and Nerve Strain

mind and the soul in medieval thought
being considered to reside in the entrails.
With the growing realization of the im-
portance of the brain as the soul and
mind organ, the tendency gained ground
to regard insanity as a brain disease, and
to limit its causes to psychic shocks and
brain lesions. In spite of this fact dis-
eases of many of the viscera have
held their place, although a subor-
dinate one, even in the text-books of
to-day.

Patients affected with phthisis and
with heart disease in their late stages,
have long been known to become in
some instances the victims of atypical
psychoses. Affections of the digestive sys-
tem and of the pelvic organs are recog-
nized as more frequent causes of insanity,
and the kidneys and liver, thyroid gland,
and practically all of the other viscera
are known to be the occasional seat of
changes which cause mental alienation.
Many cases recently described by Suck-
ling, of London, show the importance
of movable kidney as a cause of various

Preliminary 3

forms of insanity, especially mania and
melancholia.

DENTAL DISEASE. — Cases long ago
reported were regarded as showing that
even disorders of the teeth might in rare
instances cause insanity, and early in the
nineteenth century Esquirol, the great
French alienist, stated that the first
dentition by causing convulsions in chil-
dren predisposes to insanity, and that
tardy appearance of the teeth sometimes
causes it.

In 1876 the English alienist, Savage,
reported a number of cases of insanity
terminating by acute illness ; among them
that of a man of twenty-two, of bad
heredity, who became maniacal, rode
madly about the country, was unmanage-
able, and brought to the asylum. After
three or four months he developed a
severe toothache which he endured for a
few days and the tooth was then pulled.
There was pus at the ends of the roots.
The patient recovered promptly from his
mania. Another patient reported by

4 Insomnia and Nerve Strain

Savage recovered from mania after the
development and evacuation of an
alveolar abscess. These are mentioned
by Lauder Brunton in an essay as cases
of insanity due to diseased teeth.

Similar cases have been reported from
time to time, and lesions of the teeth find
occasional mention in some of the older
text-books of mental disease. Dental
works still speak of insanity and many
other functional nervous disorders as
occasionally due to dental lesions. Mod-
ern psychiatry takes no account of these
scattered cases, and I am not aware that
any one has ever looked for dental dis-
ease as a cause of insanity, or attempted
a cure by its eradication.

There seems to exist among physicians
not only a disregard but a distinct though
mild dislike of the teeth as organs to be
reckoned with medically, they being as
it were an Ishmael, not to be admitted
to their pathologic birthright. Lauder
Brunt on 's essay on the subject is too
little known and heeded, and few such

Preliminary 5

systematic attempts have been made to
correlate their disorders with the suffer-
ings of the human race, except for the
most obvious phenomena of pain. Ordi-
nary pain at a distance, as headache or
neuralgia due to the teeth, though well
known is commonly disregarded. Even
the various reflex nervous phenomena
in children, convulsions, fretfulness, and
fever, are not now ascribed to the irrita-
tion either of teething or of dental caries,
but to digestive disorders. The state
of recent opinion as enshrined in epigram
is that the result of teething is nothing but
teeth.

DISSOCIATION OF SYMPTOMS. — The
present attempt at a study of the sensory
phenomena of dental lesions had its fons
et origo in an observation made in a case
of ordinary toothache that the depression
and insomnia did not vary in direct ratio
with the pain, but were sometimes
marked when the local pain was slight.
The symptoms being thus discovered to
be dissociated phenomena, the disjecta

6 Insomnia and Nerve Strain

membra of a symptom complex, a pro-
visional theory was formed subject to
correction by further study, that tooth-
ache is no more the cause of insomnia
than is this the cause of the ache, but that
both are in equally direct dependence on
the dental lesion. In view of the possi-
bilities thus raised the demonstration of
the independence of all the concomitant
symptoms of dental lesions seemed to
acquire importance, and an investigation
was entered upon, at first of cases of mel-
ancholia, and later of mania and dementia
precox, with this point in view.

INCIDENCE OF DENTAL LESIONS. — The
occurrence of the commoner lesions, caries
and abscess, can hardly be considered to
have much significance without a study
of the effect of their removal on the course
of the disease. It was early apparent
that a rarer condition, dental impaction,
was relatively common in these patients.
Of about fifty-two cases examined in the
Cleveland, Massillon, and Columbus State
Hospitals, through the courtesy of their

Preliminary 7

respective superintendents, twenty-five
patients were suffering from impacted
teeth, many of them having several
lesions of this kind.

To make a test of the ultimate value
of the relief of this condition, on patients
insane, many of them for long periods,
and many demented, must be the work
of some years. Meanwhile the cases seen
in private practice, most of them of
shorter duration, many suffering from
the milder dental lesions, have presented
some points of interest and have seemed
worthy of collocation with cases, seen dur-
ing the past fifteen years, of neuroses and
psychoses due to disease of other viscera.
The surprisingly frequent dental irrita-
tions in a way supplement these others,
and stop a gap both diagnostic and thera-
peutic in the study of the nervous results
of visceral lesions. To this fact is largely
owing what may seem an undue prepon-
derance in number of dental cases cited.

The main theme of the present work is
a provisional sketch of the mode of origin
of the psychoses. An early presentation

8 Insomnia and Nerve Strain

is made in the hope that others may be
induced to consider the field a promising
one for further study.

HEAD'S RESEARCHES. — It is necessary
first to consider the general features of
the sensory system in order to appreciate
the possibilities of the genesis in it of
emotional and mental disease. Fortu-
nately the study of the afferent nervous
system published by Head, Rivers, and
Sherren in Brain, November, 1905, renders
this possible.

In order to make a thorough investiga-
tion of conditions in the parts of the skin
supplied by peripheral nerves, Dr. Head
caused the radial and external cutaneous
nerves to be divided in the neighborhood
of his own hand and elbow and after-
wards subjected his arm and hand to sys-
tematic examinations. The result was
the discovery of three distinct forms of
sensibility, the first of which he calls deep
sensibility, supplied to the deeper struc-
tures by afferent fibres running with the
motor nerves. The result of pressure is

Preliminary 9

pain which is fairly accurately localized.
This function persists after the cutaneous
nerves of a part have been thoroughly
divided.

The skin is found to possess two forms
of sensibility, one the epicritic, by which
one appreciates light touches localized
with considerable accuracy, and impres-
sions of warmth and coolness.

The other form of sensibility is called
by Head protopathic. It is deeper in lo-
cation than epicritic sensibility, not being
evoked by light touches but by compara-
tively deep pin-pricks or by heat or cold
or touching or pulling hairs. It is peculiar
in giving a sensation that when intense
is a distinct pain, not well denned but
widespread and radiating. When located
it may not be at the point stimulated but
at some distance.

Protopathic sensibility is recovered
sooner than is the epicritic variety, and
with this recovery trophic changes con-
sequent on division of the nerves disap-
pear. Recovery of protopathic function

io Insomnia and Nerve Strain

in Head occurred in seven weeks, and
was complete in twenty-nine weeks,
while the epicritic fibres were not fully
restored a year after the operation.

After the protopathic fibres had re-
covered their function and while epicritic
sensibility was still lacking, it required
a stronger stimulus than normal to cause
pain, but the response was excessive and
was accompanied by an irresistible im-
pulse to draw the hand away. This
indicates a certain amount of control
of the protopathic by the epicritic sys-
tem.

VISCERAL SENSIBILITY. — Sensibility of
the viscera corresponds very closely with
that supplied by the protopathic system
to the skin. Their nerve-supply must be
regarded as a part of the same mechan-
ism. Head found that heat and cold,
when applied within the walls of the in-
testines, were said by patients to be un-
comfortable, but the sensation was never
localized in the abdomen. They gave a
burning or cold feeling, sometimes on the

Preliminary 1 1

skin and sometimes in the air entirely
outside the patient's body.

In the viscera deep sensibility seems
to be subserved by the end-organs of
Pacini and probably gives some indication
of movement and position.

It is evident from Head's researches
that the epicritic system is mainly con-
cerned with localization and the represen-
tation of sensation in consciousness, that
is to say, in the cortical receiving centres.
The deep and protopathic systems supply
information that is often dim and may
not be present in consciousness at all.

In investigating the relations existing
between disorders of sensation as they
affect emotion and mentality in func-
tional nervous disease, it has not been
possible to separate the deep and the
protopathic systems. The relations of
the epicritic system with regard to the
other two are more clear, but throughout
this work when the protopathic system
is spoken of it may be taken to include
the deep system. In the same way the
epicritic and voluntary functions of the

12 Insomnia and Nerve Strain

cortex are distinguished with compara-
tive ease from those of the lower centres,
but when basal ganglia are spoken of they
are meant to include not only the gangli-
onic masses at the base of the brain, but
the spinal cord as well.

IRRITATIVE THEORY OF THE NEURO-
PSYCHOSES.— The view here taken of the
neuroses and psychoses in general is that
they are primarily irritative disorders of
the sensory system affecting the remain-
der of the nerve mechanism indirectly.
The irritants are either mechanical or
toxic, and the discussion of their location
and mode of action may be deferred until
later.

ILLUSTRATIVE CASES

Among the diseases to which mankind
is subject dental caries is probably the
most common, and of dental caries and
other disorders of the teeth insomnia is,
I believe, much the most common symp-
tom, often occurring without local pain

Illustrative Cases 13

or indication of its place of origin. It is
usually accompanied by other indications
of disordered nerve-action. The follow-
ing case is among the more simple in-
stances.

CASE i. INSOMNIA. — The patient was
a young business man thirty years of age
previously in good health. When seen
he had been suffering from persistent
sleeplessness without obvious cause for
about a year. He had been working
hard but was under no financial strain,
and had simply noticed an increased
difficulty in going to sleep and tendency
to waken after a few hours. He drifted
into the habit of taking the usual hyp-
notic drugs, felt rather weak and nervous
during the day, and was quite unable to
work. He was unusually sensitive to
noise and light.

Skiagraphs of his teeth showed no
lesions with the exception of a number
of cavities, one of which affected the
pulp-chamber. Convalescence began be-
fore his dental work was finished and was

H Insomnia and Nerve Strain

continuous so that within a few weeks
he was sleeping well without narcotics.

Neither in this nor in any other of the
dental cases has there been toothache or
other localizing symptom referable to the
teeth except as noted. ^

CASE 2. INSOMNIA. — Insomnia is so
constant a factor in the life-history of
many people as to be considered consti-
tutional. These cases, however, are on
a basis of distinct physical disease. One
patient recently seen, a man sixty years
of age, has for the last thirty or thirty-
five years had more or less insomnia,
lately consisting of an early wakening
usually at about four o'clock. Dur-
ing the earlier years of his life he was
sometimes persistently sleepless for long
periods without pain or obvious cause.
Skiagraphic examination showed a con-
dition of the teeth dating back to a be-
ginning many years ago. Two of the
teeth were set in pus pockets, very loose,
and had at times been ulcerated. Two

CASE 5. — Melancholia. Impac-
ted upper left third molar.

CASE 14. — Hysteria. Impacted
lower left third molar.

CASE 15. — Acute Mania. Impac-
ted cuspid tooth.

Case of Hysteria and Melan-
choly of many years' standing.
Impacted upper right third molar.

CASE 16. — Incipient Dementia Precox. Impac-
tion of all of the wisdom teeth. One upper and one
lower impacted tooth are here shown.

Illustrative Cases 15

of the other teeth had abscesses at the
roots. The two teeth most diseased were
drawn and the others treated. The pa-
tient has since been sleeping through the
night without wakening, for the first time
in many

/ CASE 3 . INSOMNIA : ARTERIAL DISEASE.
—One of the complications of insomnia
which is of more than usual importance
is arterial disease. Worry and other
emotions are thought to create arterial
tension as an important factor in causing
arterio-sclerosis. The underlying phys-
ical element which exists in many such
patients is illustrated in the following
case.

A business man sixty-five years of age
began six years ago to suffer from insom-
nia consequent, apparently, on worry
over his financial affairs. For more than
two years he suffered from marked in-
somnia and great mental anxiety and
then broke down in health. He had a
slight stroke of paralysis, suffered much
with bad feelings in his head of an indefi-

16 Insomnia and Nerve Strain

nite character but without local pain.
An examination of his teeth showed that
they were in very bad condition and
skiagraphs revealed multiple abscesses
in both the upper and lower jaws. Ex-
traction of some of the teeth was followed
by marked relief, but the case remains
incomplete therapeutical!^.

CASE 4. MELANCHOLY. — Equally sim-
ple and common are the cases of melan-
choly running into mild melancholia with
somewhat perverted introspective ideas
rather than genuine delusions. Of this
a typical example is the following: A
wealthy man thirty-five years old, with
no business cares, has had for the last
twelve or fifteen years occasional attacks
of depression lasting from two or three
to ten or twelve months. When first
seen he had been depressed for several
months, thought that he could not recover
and considered himself a nuisance to
his family. He had had no pain of any
kind. During some of these attacks sleep
had been disturbed, but when seen he

Illustrative Cases 1 7

was sleeping well and had a fairly good
appetite. Skiagraphs showed irritation at
the roots of a few of the teeth and an
abscess at the roots of one molar tooth,
which was treated for some time but
finally had to be drawn. He made a
progressive and rapid recovery.

' CASE 5. INSOMNIA: MELANCHOLY. —
A somewhat whimsical element is intro-
duced into the following case by the
psychic cause, although the symptoms,
except for their short continuance, were
of a much more serious character.

A robust mechanic twenty-eight years
of age, three weeks before he was first
seen came home from his work, and his
wife moodily remarked that she thought
she was losing her mind. It immediately
occurred to him that he might be losing
his mind. He slept little that night or
the succeeding nights, gave up his work
and spent his days in fear of the asylum.
In brief, tonics and assurances failed to
relieve. The only discoverable lesion
was dental caries, and the filling of a deep

1 8 Insomnia and Nerve Strain

cavity extending into the pulp was fol-
lowed by prompt recovery and return to
work. There had at no time been tooth-
ache or other pain, but dizziness and
sweating had been noted.

CASE 6. INSOMNIA: MELANCHOLIA. —
Such cases as the above merge gradually
into typical melancholia of the profounder
kind. An unmarried woman, twenty-
seven years old, a teacher, for a year had
been profoundly melancholy with in-
tractable insomnia, delusions of various
deadly sins, and entire hopelessness of
recovery. Restlessness was extreme,
tonic and local uterine treatment were
of no avail. As a last resort the teeth
were examined. They were apparently
in perfect condition. A skiagraph
showed an impacted right upper third
molar tooth pressing against the second
molar, a condition obviously capable of
causing irritation. The symptoms, in
about a week after the removal of the
tooth, began to improve. Recovery was
complete in six or eight weeks, and has

Illustrative Cases 19

persisted. There had been at no time
pain or other localizing symptom.

The investigation of dental conditions
early in its course took more definite
shape in the examination of the third
case observed, through the advice given
by Dr. John F. Stephan, to have skia-
graphs taken of the teeth in order to a
thorough elucidation of the conditions.
The examination of the first patient by
skiagraph showed negative results. The
recovery of the second patient took place
by dental treatment without skiagraphic
examination. In the third patient, how-
ever, the teeth on inspection seemed to
be in unusually good condition but an
impacted third molar tooth was present
and its removal was followed by recovery
from melancholia. This is the case just
cited in the present series.

CASE 7. MELANCHOLY OF DENTAL
ORIGIN. — In this connection Dr. Stephan
imparted to me the following interesting
observation which he had previously

20 Insomnia and Nerve Strain

made. A patient in whom suppuration
was present at the roots of one of the
teeth was subject to a depression which
seemed to her like a cloud enveloping
her. On opening the tooth the cloud
lifted. When the tooth was closed there
invariably followed within about an hour
a settling down of this emotional cloud,
even when the patient supposed that the
tooth had simply been treated but not
closed. The result was invariable on
several trials so long as the abnormal
dental condition persisted.

CASE 8. MELANCHOLIA. — Emotional
variations which accompany disorders
of the abdominal and pelvic viscera
are so common as to be matters of daily
observation. It is of special importance
to realize that there is no essential differ-
ence between mild cases of this character
and the severer cases of melancholia and
mania which, due to the same cause,
present all of the mental symptoms char-
acteristic of what are considered true
psychoses. The clinical picture of agitated

Illustrative Cases 21

melancholy is, in my experience, often met
in connection with gastric and intestinal
disease. Mild melancholy is an almost
regular accompaniment of indigestion,
and this under exceptional conditions
may rise to a condition of frenzied
depression with intractable nervousness
and insomnia.

One such patient, a man sixty-three
years of age, in whom the attack of
mental alienation followed dysentery, re-
sponded readily and rapidly to purgation,
milk diet, and the salicylates, when
hypnotics and sedatives were powerless
to give more than the slightest relief.
In this case, insomnia, agitation, and
depression were extreme, and the symp-
tomatic diagnosis of melancholia agitata
was amply justified by the conditions
present.

CASE 9. MELANCHOLIA. — The cause in
the preceding case was obviously physical.
In the following instance the exciting
cause was psychic, so purely as almost
to exclude the probability of a physical

22 Insomnia and Nerve Strain

basis. The patient was a woman, fifty-
five years of age, fat, florid, and always in
perfect health. Three months before she
was first seen, her husband accidentally
shot himself and she was in consequence
much alarmed and agitated. The wound
proved to be a slight one, but she found
herself depressed in spite of this fact, and
during the whole intervening time until
I saw her she was sleepless at night, heavy
and depressed by day, and was firmly
convinced that she was insane and would
be sent to an asylum. Little could be
made out with regard to the abdominal
organs on account of the layer of fat.
Physical examinations gave negative
results. The only apparent anomaly was
loss of appetite with moderate flatulence.
However, on milk diet, laxatives, and in-
testinal antiseptics, sleep promptly re-
turned without hypnotics, although these,
even in rather large dosage, had previ-
ously failed to relieve. She made a pro-
gressive recovery.

CASE 10. MELANCHOLIA. — The follow-

Illustrative Cases 23

ing case is in appearance simple. Psy-
chic shock was followed by a digestive
difficulty as the physical basis of dis-
ordered function. The patient was a man
forty-two years of age who in general had
been in good health. Some four years
before he was seen he went through a pe-
riod of business anxieties. He was also
overworked for several years and finally
began to notice that he was unable to
work as well as usual. He became de-
pressed and anxious and had a definite
feeling of sinking in the epigastrium. He
had no ringing in the ears or tingling in
the hands, but had a full feeling in the
head with more or less throbbing. No
especial examination was made at that
time for dental lesions and in this respect
the case remains obscure. Periods of
very great depression would come on,
lasting for some hours, and would then
pass off, leaving him comparatively free,
although far from well. His paroxysms
of depression were apt to come soon after
meals. In a few months they were par-
tially replaced by attacks of intolerable

24 Insomnia and Nerve Strain

itching. This came quite irregularly,
sometimes several times a day and some-
times not for a week or two. They lasted
from one to twenty minutes. His back
and the backs of his hands were the parts
most affected. This itching was at times
accompanied by a red rash along the front
of the arms, which was called urticaria by
the physicians who saw it. The patient
describes it as an itching which did not
incline him to scratch, but was like a
prickling sensation as of needles stuck
through the skin from within out. All
sorts of applications were powerless to
relieve this condition. It was diagnosed
as an affection of the vaso-motor nerves
by every physician who saw it. Baths
and many forms of medication were tried
without effect. The patient was seen by
many eminent practicians and special-
ists. Meanwhile the continual worry and
depression were present, but somewhat
better.

Two years after the beginning of the
disease, the patient himself insisted on a
chemical examination of the stomach

Illustrative Cases 25

contents. A slight subacidity was found ,
attributed by the examining physician
to nervous dyspepsia. He prescribed
seven drops of dilute hydrochloric acid,
but said at the time that it would proba-
bly not be effectual in relieving the symp-
toms. It is significant that the attacks
of itching were always accompanied by
psychic pain, with a feeling of tension in
the frontal region. The patient would
then have an inclination to sleep, and
would awake feeling much refreshed.

The very first dose of hydrochloric
acid was followed by complete relief
from both the itching and the psychic
pain. The acid was taken two or three
times a day for six weeks and ever since
that time it has been taken when needed.
It is invariably effective and there has
never been a return of very severe itching.
Some attacks of depression have occurred
so that several times the patient has felt
as if he might have to give up his work.
On taking the acid, however, for a few
days he has invariably recovered from
this feeling.

26 Insomnia and Nerve Strain

Certain things have disagreed with
the patient. He thinks that sweet
things — eggs, milk, and in general things
which make him feel bilious — are to be
avoided. The patient has now been in
good health for thirteen years.

CASE ii. MELANCHOLIA. — The follow-
ing is a case common enough in its
essential features but too often unrecog-
nized as regards the physical substratum.
The patient, a woman thirty years of age,
took up an amount of mental work
that involved moderate overstrain. Al-
though at the time she was in unusually
good health, she soon began to be sleepless
and depressed, and developed delusions
that she was pregnant and that she had
committed various unpardonable sins,
and procured a revolver with a view to
committing suicide. When seen she had
grown steadily worse for two or three
months. She had the usual coated tongue
and pallor of the melancholic, tired
easily, had no energy, and was much
occupied with her delusions. Examina-

Illustrative Cases 27

tion revealed serious disease of both
uterus and ovaries. Great improve-
ment in the mental condition was appar-
ent within a few days after an operation
undertaken to relieve the pelvic condi-
tions. The patient gained steadily in
strength and cheerfulness for about a
year, and is now, six years after the
operation, in good health.

CASE 12. MELANCHOLIA. — The follow-
ing history is communicated to me by Dr.
Humiston, who rescued the patient after
some months of asylum residence. She
was seen by me for the first time during
her convalescence. The patient, a woman
thirty-five years old, became profoundly
melancholy after the birth of a child.
She thought her own soul and those of her
immediate family lost through her fault.
The onset of her illness was quite acute,
with a severe headache forty-eight
hours after the birth of the child,
and was attended with intense agita-
tion and sleeplessness. She had no pain,
but complained that her head felt as if

28 Insomnia and Nerve Strain

it had been split open and her soul ex-
tracted.

The uterus, which was much inflamed
and in a fibroid condition, was curetted
and fixed in normal position. Between
three and four weeks after the operation
the patient was discharged from the
Hospital, cured physically, and much
improved mentally. Although more
cheerful she still suffered from delusions.
Recovery, however, was uninterrupted
from this point, and the patient has
remained in good mental health and
great physical vigor for twelve years.

CASE 13. NEURASTHENIA. — The asso-
ciation of neurasthenia with varied dis-
eases of the abdominal and pelvic viscera
is significant. Such patients as the
following are common and persistent
apparitions in the waiting-room. The
patient was a woman forty years of age.
She was fairly well until the birth of her
first child some years ago. After that
time she had a great deal of trouble with
her stomach, had to be careful of her

Illustrative Cases 29

diet, and suffered a great deal from
backache and headache. For three or
four years she spent most of the time
in bed and was much weakened and
emaciated.

Her menstruation was regular and not
especially painful but it was attended
with considerable prostration. For six
or eight months before she was first seen
she had been in bed continuously, and
was eating only eggs, broiled beef-steak,
and dried bread. She had attacks of dis-
tress in the stomach and a distinct draw-
ing feeling from the stomach to the head.
These feelings were relieved by taking
food, which she did quite frequently. The
predominant symptoms, however, were
purely nervous, great sensitiveness to
physical and psychic shocks and prone-
ness to fatigue, giving her illness the
unmistakable impress of the fatigue neu-
rosis of gastro-intestinal type.

The patient was miserably emaciated
and weak but not anemic. The abdom-
inal organs appeared normal, the tongue
slightly coated ; the pulse eighty, soft and

30 Insomnia and Nerve Strain

regular. The urine contained a slight
amount of albumin but no sugar and no
casts. The specific gravity was 1.026.

Gastric hyperacidity was diagnosed,
and marked relief followed the frequent
giving of bicarbonate of soda in large
amounts. Radical cure, however, was
only obtained by curetting the uterus and
removal of both ovaries, which were
badly diseased. This was successfully
carried out by Dr. W. H. Humiston, to
whom I am indebted for constant co-
operation in this and other similar cases.
Recovery was slow and the management
of the case difficult. The patient has
now been in good health for more than
ten years.

CASE 14. HYSTERIA MINOR. — While
hysteria major comprises cases present-
ing certain definite and severe symptoms,
hysteria minor is a vague term applied
to a great variety of conditions. The fol-
lowing case, communicated to me by a
colleague, might be considered hypomania,
but corresponds more nearly with the

Illustrative Cases 31

conception of a severe but not major
attack of hysteria. The patient, a young
married woman twenty-five years of age,
rather suddenly, in November, 1907,
developed fearful pain in her head with
attacks of hysterical screaming. She
began to be very nervous and sleepless,
cried easily, and lost weight rapidly. On
the 3oth of December an impacted lower
third molar tooth was removed. On the
1 7th of January, 1908, she was better in
other ways but the screaming attacks
continued. She was given bromids and
frequent nourishment. Improvement
began on this regimen, and at about this
time pain developed in an upper incisor
tooth. An abscess was discovered and
the tooth removed. The screaming at-
tacks stopped at once and she has since
been perfectly well.

CASE 15. MANIA. — The excited phase
of the manic-depressive group is well
represented by the following fairly typi-
cal case of acute mania. The patient
was a physician, twenty-eight years of

32 Insomnia and Nerve Strain

age, first seen a week after the maniacal
condition was first noticed. He had
overworked for the last year or two and
for a time had been sleepless, but it was
not possible to ascertain exactly how long.
Otherwise he was considered well. Dur-
ing the preceding week, however, he had
acted in a peculiar way, laughing and
talking foolishly but insisting that there
was nothing the matter with him. For
some weeks he had complained of mod-
erate pain in one of his teeth. When
seen he was rational but inconsistent and
foolish in his talk and somewhat inco-
herent. By skiagraph the right upper
first bicuspid tooth was found badly
impacted and was drawn. For a week
or ten days he was unmanageable, but
then began to quiet down, slept well, and
has gone on to a progressive recovery.

CASE 16. INCIPIENT DEMENTIA PRE-
cox. — The preceding case might be appre-
hended as one of beginning mania or of
dementia precox. The two conditions
merge into each other, and the diagnosis

Illustrative Cases 33

in such a case is of prognostic but not
theoretical importance. The following
case, however, is one of a somewhat differ-
ent character. Though it might at first
sight seem mild, its manifestations have
the importance which attaches to patients
who are mentally affected but hardly
in condition to be sent to a hospital.

The patient is a bright boy of sixteen,
the son of an unusually intelligent pro-
fessional man. Until a year before he
was seen he was well, of a bright, cheerful
disposition, and a general favorite. This
was with the exception, however, of very
moderate nervousness and some frontal
headache during the last two or three
years. During the last year his disposi-
tion changed. He became somewhat
morose and irritable, and showed less
affection for his family and friends than
before. He was increasingly nervous
and restless so that he could not sit or
read long and only had four or five
hours of sleep during the night. He also
had practically constant frontal head-
ache and a severe feeling of oppression

34 Insomnia and Nerve Strain

in the occipital region, but no neuralgic
or dental pains. He was often dizzy,
especially when he bent his head. Being
athletic and strongly built he suffered
from a good many kicks and blows on the
head in playing football. The right
occipital region was somewhat sore to
pressure and on pulling the hair.

On skiagraphic examination all four
of the molar teeth were found impacted.
The left lower third molar was extracted
first, and the feeling of pressure at the
back of the neck immediately disappeared,
and from that time on sleep was some-
what better. The upper third molar
teeth were extracted three weeks later,
and on the night following their extrac-
tion he slept soundly for ten or twelve
hours. After this he slept well every
night, but within a few weeks became
restless once more and the bad feelings
returned to his head. The right lower
third molar tooth was then extracted,
and the head pains were once more
relieved. Sleep has continued good, the
patient has gained in weight steadily,

Illustrative Cases 35

has had a good appetite, felt quiet,
and his family have noticed a marked
change in his demeanor. He has re-
gained his affectionate bearing toward
them.

In writing of him recently his father
said: "We noticed a great change in
John's conduct compared with that pre-
vious to the time when you first saw
him. This became more noticeable after
the last extraction. He has been gentler,
more tractable, affectionate, regular in
his habits, and more natural in every
way. I think that physically he has been
much weaker than six months ago. I
suppose the nervous shock incident to
the operations may account for that.
Though less nervous and excitable, he
tires with the least exertion and requires
a great amount of sleep. His appetite
has increased every day. He has not
had any desire for tea, coffee, or hot
drinks, but is perfectly satisfied with
cold water."

With regard to the weakness noted in

36 Insomnia and Nerve Strain

this case, it is a common sequel of the
removal of a mechanical stimulus. The
restless expenditure of energy is replaced
by languor, and the exhausted ganglion
cells should be given a good many
months of repose before being called on
for much exertion.

CASE 1 7. INCOMPLETE DEMENTIA PRE-
cox. — The importance of peripheral irrita-
tion in the members of the community
whomGrasset calls the Semi-insane and the
Semi-responsible, suggested in the above
case, is also of interest in the following
recital of his life-experience given to
me recently by a friend in the legal
profession. The subject of this little
autobiographic sketch is now forty-three
years old. He says he was always
difficult to manage at school, but was well,
robust, and muscular. When he was a
boy he had a controversy with a teacher
and left school at the age of sixteen. At
that time he struck out for himself. He
then suffered for ten years from an
uncontrollable impulse to wander. He

Illustrative Cases 37

began also to have neuralgic attacks,
sometimes on one side of the face and
sometimes on the other. These per-
sisted for ten or twelve years and then
ceased. Pain was severe in the third
molar region, especially in the lower
jaw on the right side, and there was pain
in the other teeth, both upper and lower,
and pain in the face. Drugs failed to
control the pain, even a grain of morphin
being quite useless. The left lower first
molar was extracted when the patient
was thirteen years old, and this seems to
have removed the pressure from that
region for no pain was felt in the lower
jaw on that side. Between the ages of
eighteen and twenty-five he had occa-
sional attacks of moderate depression.
The patient's wandering was all over the
country, mainly, however, in the west, and
was usually by bicycle or train, but when
he was out of money he beat his way on
freight trains. During the last fifteen
years or so the impulse to wander has not
been irresistible, but the patient travels
when it is convenient. He has been

38 Insomnia and Nerve Strain

able to study his profession and engage
in successful practice.

CASE 1 8. DEMENTIA PRECOX. — The
next case is one of typical hebephrenia.
The patient is a girl nineteen years of age
who was never very strong but not
especially nervous. In February, 1907,
she began to be low-spirited, cried fre-
quently, and was afraid that she would
lose her mind. Her hands and feet
began to be cold, and she was especially
depressed and weak before her menstrua-
tion. In June she began to talk of
religious matters, prayed, and expounded
the Scriptures. During July and August
she talked, sang, and played on the
piano incessantly, was excited and very
contrary. In September she was better,
but early in October ran out into the
street and tried to escape. Since then
she has torn her clothing whenever it
was possible, has bitten and scratched
her relatives, and been resistant and often
angry. She has been persistently sleep-
less throughout her illness. She has had

CASE 1 8. — Dementia precox. Impaction of a
lateral incisor and all four wisdom teeth. The in-
cisor and one lower third molar are shown above.

CASE 1 8. Dementia
Upper third molar.

precox.

CASE 22. — Mania,
lower third mclar.

Impacted

Case of profound melancholia,
with subconscious sensory reflex
in upper incisor teeth. Impact-
tion of upper third molar.

Upper fourth molar tooth.

Illustrative Cases 39

no pain of any kind, neuralgic or otherwise,
and has often said that she wished she
had pain. During the latter part of her
illness she kept her hands to her head and
neck, a part of the time moaning, and
trying to escape. She was pale, emaciated,
and had the drawn, haggard look of many
such cases. There have been cases of
insanity in the family.

When seen in October it was suggested
that, as an examination of the pelvic
organs and of the teeth was impossible
without an anesthetic, skiagraphs be
taken under ether, a vaginal examination
made, and any necessary operative pro-
cedures undertaken at once. After two
months' delay, as her condition remained
unimproved, this was done. Skiagraphs
developed at once showed impaction of
all four of the third molar teeth and of
the right upper lateral incisor. The
pelvic examination showed moderate
retro version, but no pelvic lesion adequate
to account for the symptoms. The sec-
ond molar teeth in the lower jaw were
extracted to allow the removal of the

40 Insomnia and Nerve Strain

third molars impacted against them.
The third molar teeth were all removed,
as were the right lateral incisor and one
of the teeth against which it was im-
pacted, the right cuspid tooth. For
some days after the operation the patient
was rather more restless. Then she
became quieter, and it was noted that she
put her hands to her neck and head less
often than before. Her hands and feet
were warm. She began to sleep rather
better. From this time on she gained in
weight and strength, her color was better,
and hypnotics were soon discontinued.
Of late screaming fits have developed. Al-
though much of her improvement has
persisted, her case is incomplete, and a
year will probably be necessary to deter-
mine the result.

DR. O'BRIEN'S CASES. — For the fol-
lowing cases I am indebted to Dr. John
D. O'Brien of the Massillon State Hos-
pital. They are of recent observation
and are selected as examples of what
may be expected among the more imme-

Illustrative Cases 41

diate results of investigation and treat-
ment of dental lesions, the first of the
cases having been examined by skiagraph
in October, 1907. Dr. O'Brien has many
other patients at present under observa-
tion for further study.

CASE 19. MANIA. — The first patient
is a robust young man, eighteen years of
age. He was admitted to the Hospital
in the excited phase of a first attack of
manic-depressive insanity. He was irri-
table, destructive, and rather profane.
There were found an impacted left lower
third molar tooth and an abscess with
impact ion of the right lower third molar.
Extraction of the affected teeth was fol-
lowed by recovery in a few weeks and the
patient has been discharged.

CASE 20. MANIA. — The second patient
was also in a first attack of mania, excit-
able, pugilistic, destructive, filthy. There
were found an impacted left lower third
molar tooth with abscess formation,
and also a large abscess at the base of a

42 Insomnia and Nerve Strain

filling in another tooth. Extraction has
been followed by amelioration of most
of the mental symptoms.

CASE 21. MANIA. — The third patient,
twenty-five years old, was also in a typi-
cal maniacal condition, having had one
such attack previously. There were
found an impacted third molar tooth, an
irregularity and projection forward of
the upper incisor teeth with great dis-
placement and a right upper second molar
tooth impacted at right angles. Extrac-
tion was followed by marked mental and
physical improvement, and the patient is
practically ready to leave the Hospital.

CASE 22. HYPO MANIA. — The next case
was one of a first attack of hypomania
in a man twenty-five years old. A left
lower third molar was found impacted.
Recovery followed extraction very
promptly and the patient has since been
discharged.

CASE 23. DEMENTIA PRECOX. — The

Illustrative Cases 43

fifth case was one of dementia precox of
the katatonic form, in a young man
twenty years old. There were found
impaction of a left upper third molar
tooth and impaction of a right upper
third molar with abscess formation. Re-
covery followed extraction.

CASE 24. MELANCHOLIA. — The sixth
case was one of depression with marked
suicidal tendencies in a man twenty-four
years of age. He had never complained
of his teeth. Skiagraphic examination
showed an abscess involving the second
and third molars of the upper jaw on the
right side. Extraction was followed
by recovery and the patient has been
discharged from the Hospital.

CASE 25 . MELANCHOLIA. — The seventh
case was one of depression with marked
emaciation in a man forty years of age.
In this case there had been a pre-
vious attack of hemiplegia. Multiple ab-
scesses were found in the upper j?w.
Recovery followed extraction of the

44 Insomnia and Nerve Strain

teeth and evacuation of many pockets
of pus.

SLEEP AND FATIGUE

INSOMNIA. — Insomnia is a symptom
rather than a disease, and although it is
not invariable in the neuro-psychoses it
may be considered as practically the
recurring link which binds them together.
In order to understand the phenomena of
insomnia, it is necessary to make at least
a tentative definition of sleep.

Whatever else sleep may be, it must
be mainly unconsciousness, though not
alone a modification of cortical function.
This is attested by the fact that the
cortical centres of memory sometimes con-
tinue their activity during sleep and that
the motor and even the perceptive cen-
tres are active in somnambulism. The
negative element of sleep, rest through
inactivity, is possible in varying intervals
to all the tissues of the body. The active
part of the process is peculiar to the
brain, which shares the inactivity and

Sleep and Fatigue 45

adds disjunction of the higher from
the lower ganglionic levels in degree
varying with the profoundness of the
sleep. Thus comparative rest is com-
patible with waking. Considerable activ-
ity may go on in the dormant condition,
but this activity contains a relatively
small amount of interchange between
the ganglionic levels.

The subjective element of insomnia is
necessarily the conscious activity of the
cortex. The natural inference is that
sleep is banished because the cortical
processes of perception and thought go
on. An objective study, however, of
cases of insomnia shows clearly its fre-
quent dependence on the activity of the
lower centres. Comparison of the cases
just cited discloses the fact that proto-
pathic irritation is accompanied by insom-
nia in the majority of instances. If the
patient makes his insomnia an object
of study he very often finds that wake-
fulness is persistent without thought
on any special topic, and that even
when waking, the thoughts which crowd

46 Insomnia and Nerve Strain

on his mind come later, gaining power
gradually and only intensifying, not
causing the condition. Even in so uncer-
tain a science as medicine, the effect
does not precede the cause.

THE FATIGUE NEUROSIS. — Neuras-
thenia in the wider sense is too indefinite
a concept to discuss in detail. One of its
prominent symptoms, however, fatigue,
is common to many cases of protopathic
irritation and should be distinguished
from another result of such irritation,
exhaustion.

The condition of a ganglion cell which
has been irritated until incapable of
further functional activity is one of
exhaustion. This point may be reached
either with or without fatigue which is
a protective feeling inhibitory to the
action of the cell. The normal feeling of
fatigue is according to some authorities
due to poisons which accumulate as
waste products. As a result of muscular
activity they are in and about the
muscles, affecting the sensory elements.

Sleep and Fatigue 47

Fatigue from mental activity can hardly
be considered a toxic action on the
ganglion cell itself but might conceivably
result from toxic action on the smaller
cerebral vessels.

However this may be, it is important
to recognize the fact that fatigue often
occurs practically without any exertion
whatever. It may be from the action of
extrinsic toxins carried in the general
blood -stream and is one of the common
phenomena of purely mechanical proto-
pathic irritation. Dental caries and
impaction, gastroptosis and the torsion
of a movable kidney are frequent causes
of the heaviness in the limbs as well as
the thrills and wavy feelings so typical
of the neurasthenic condition. This
symptom may occur with insomnia or
may alternate with it after the curious
manner of rotation of protopathic symp-
toms in general. A further explana-
tion of fatigue will be sought later in
connection with other phenomena of
action and reaction in the nervous
system.

48 Insomnia and Nerve Strain

THE EMOTIONS

MANIC-DEPRESSIVE INSANITY. — For-
merly all of the insanities more or less
emotional in expression and not
otherwise classified were included in
mania and melancholia. The conception
of the psychoses here presented is that
they are due to a common set of physical
causes, and merges all neuroses and
psychoses as one essential process with
infinitely varied results, like the har-
monies and discords of a piano with one
key-board and one performer. No essen-
tial difference in symptoms exists between
the different psychoses, as they blend in
infinite variety. Mania and melancholia
are only somewhat more predominantly
emotional than the others and the results
of study of the emotions in these disorders
are equally applicable to other members
of the functional group.

Considering then melancholia and
mania as the psychoses predominantly
emotional, a study of their phenomena
compared with the emotions which con-

The Emotions 49

stitute so large a part of normal human
activity develops the fact that no distinc-
tion can be drawn between normal and
diseased emotion, that is emotion exists
in absolutely unbroken series, from the
lightest reflexes of a passing word or
thought to the most profound result of
the extremest physical or mental shock.

PHYSICAL BASIS OF THE EMOTIONS. —
The facts pertaining to the normal emo-
tions are ably presented by William
James in his Psychology. According to
his view normal emotion, whether from
physical or psychic causes, is always due
to an altered visceral condition. A sud-
den noise or bright light or the sight of a
revolver is the direct cause of the wildly
beating heart, pallid face, motor unrest,
and dilated pupils. The emotion is the
cognition of these visceral changes. Ap-
prehension of danger is not necessary to
these phenomena, they may even appre-
ciably precede the conscious sensation of
fear. A man whose legs carry him off a
battlefield finds that the faster he runs

50 Insomnia and Nerve Strain

the more frightened be becomes. His
motor energy and wildly beating heart
intensify his emotion.

One of the best instances of what may
be called the incubation period of the
emotions is seen in the depression follow-
ing a personal misfortune. Often after
such an event there is for a time mental
exhilaration, or an apparent numbing
of sensibility occurs which may lead the
subject to think that he is callous to the
loss which he has experienced. There
follow lowered heart action, a heavy feel-
ing in the epigastrium, heaviness of the
arms and legs, and a haggardness about
the eyes which are readily apprehended
as grief, and which in persons deficient
in physical reactive power may persist
even after the removal of the exciting
cause.

MOODS. — The emotions in lighter grade
called moods have been considered by
Head in connection with the referred
pains which he has studied so thoroughly.
Such moods may, however, be caused

The Emotions 51

by visceral disease without referred pain,
notably by the toxins of indigestion and
malassimilation. A fermenting mass of
food retained in the stomach may cause
a simple depression, which it is quite im-
possible to shake off even though the
cause is known, but which is promptly
relieved by the use of the stomach-tube.
Long-continued melancholy may be
caused by deficient secretion of hydro-
chloric acid in the gastric juice, which
is relieved by the administration of the
acid.

In the mildest moods, the ordinary
stronger emotions due either to psychic
impressions or disordered viscera and
even in profound melancholia or mania
the emotion as it appears in consciousness
is the result of visceral change.

DIRECTNESS OF EMOTIONAL RESULT. —
When, as is usually the case, the emotions
are determined not by environment and
circumstance, but are the result of a
lesion, the ensuing emotion is as direct a
sequence as is the pain of a burn or a pin-

52 Insomnia and Nerve Strain

prick. This is none the less true because
these patients in thought project their
emotions into causal relation with their
circumstances.

PSYCHIC PAIN. — The difference be-
tween ordinary pain as neuralgia, and
emotional pain, psychalgia, is not great.
Ordinary pain exists in consciousness as
a percept of a destructive process in the
periphery, just as a tactile sensation is
a percept of contact in the periphery.
Psychic pain is a percept of a destructive
or calamitous process which may be
located more or less dimly in the body as
epigastric distress, a feeling of constric-
tion about the heart or other organ, or
it is perceived as a feeling of calamity
without spatial relations, projected by
intervention of the intellect into the ex-
ternal world of environment or circum-
stance. It follows from Head's later
researches on sensation that true visceral
pain, even when not translated into
psychalgia, is sometimes apprehended as
a pain or burning sensation definitely

The Emotions 53

located outside the body, and this is
much more true of the distinctly emo-
tional sequences of visceral disease.

CONTRAST BETWEEN NORMAL AND AB-
NORMAL EMOTIONS. — There is no store-
house for emotions in the central nervous
system. Memories are not in themselves
emotional. They can only revive emotion
by their effect on the viscera, an effect
similar to that of the original psychic
cause with ever weakening force as the
memory grows dim. The continuing
emotional result therefore of a grief,
sorrow, or fear grows less apparent with
each succeeding day. Memories weaken
as present impressions grow stronger, and
environment powerfully influences nor-
mal emotions.

DEPTH OP EMOTIONAL RESULT. —In
contrast with the normal emotions are
the psychoses, which invariably have as
their enduring basis a physical disorder.
The patient with mania is taken from
the scene of his work and from his home,

54 Insomnia and Nerve Strain

torn from those he loves, imprisoned in a
place naturally repugnant to him, often
with food and surroundings not such
as those to which he is accustomed. His
emotional state, however, what the Ger-
mans more compactly term the Stimmung,
is determined by his sickness, and for-
tunately for him it is joy. The melan-
cholic is more often kept at home,
surrounded by his loved ones, often
given the delights of travel, soothed by
music, and diverted in every way, but
his emotion is determined by his illness.
It is sadness so profound that these
patients cut their own arteries, bite and
swallow fragments from drinking-vessels,
hack at their throats with jagged glass.
No torment is for them too hideous to
lend a terror to the approach of death.

It may be said in general that an
emotional deviation from the normal
which persists from day to day in the
absence of an enduring psychic cause
is invariably physical and the cause
should be looked for in the viscera.
The apparent persisting cause may be

The Emotions 55

a memory either fabricated or true, but
when memory does not weaken its
endurance is the result, not the cause,
of the emotional state.

Melancholia should not be apprehended
as ganglionic sedation. It is the reverse
of this, an agony so extreme as to be
paralleled by no physical pain except
possibly the most violent renal colic or
gastralgia. The theory that mania and
melancholia are identical but that mania
represents a deeper grade of reduction
is hardly tenable. The word reduction
is misleading; the process in both in-
stances is primarily an excitation, and
mania in its milder forms is a trivial
derangement compared with the pro-
fundity of the severer melancholias.

MUTABILITY OF THE EMOTIONS. — Al-
though elation and depression are so dif-
ferent as to seem opposed, they do not
neutralize each other like an acid and
an alkali but mingle in consciousness
like bitter and sweet ; in other words we
are dealing with a vital and not a chemi-

56 Insomnia and Nerve Strain

cal phenomenon. In the easily excita-
ble whether children or adults laughter
changes to tears with proverbial quick-
ness, and a sudden stimulus may provoke
an emotion which may be termed pure
excitement without being felt with defi-
niteness as either sorrow or joy.

When manic-depressive insanity occurs
as the result of a tremendous event
whether of joy or of sorrow, the psychosis
takes color from the enduring antecedent
emotional state, so that a sudden great
joy is likely to be followed by a burst of
tears and consequent melancholia. Dis-
aster is in many instances followed by
elation and mania.

So far as emotion affects purely mental
activity, it may be considered as a force
pulling on the intellectual content.
Two such forces acting on the mind never
pull away from each other but in lines
that diverge at an angle. Here the anal-
ogy with non- vital energy ceases. The
effect on mental inertia is to move
thought and perception not on a line
lying between the other two but to some

Subconscious Sensory Reflexes 57

extent along each; in other words, and
with another analogy, emotion is not a
crucible for the fusion of thought but
stimulates it to movement in many
simultaneous ways.

SUBCONSCIOUS SENSORY
REFLEXES

SENSORY MANIFESTATIONS IN THE
PSYCHOSES. — In considering pain it is
possible to divide positive phenomena of
that nature into extrinsic pains set up
by an obvious external cause, and intrin-
sic ones, which arising in the body itself
are sometimes in the locality of the cause,
but are often due to a disorder so obscure
or distant as to leave a doubt of the loca-
tion and kind, even at times of the reality
of the noxious agent. While the skin
is the usual organ of perception of exter-
nal objects and extrinsic pains the viscera
have long been considered the main cause
of intrinsic pains and their exploration
in this relation is one of the ordinary
subjects of medical research.

58 Insomnia and Nerve Strain

The results in consciousness of proto-
pathic excitation are not only pains,
but also intense but vague feelings of dis-
comfort, waves, thrills, and tense feelings
in viscera, body, or extremities. The
greater and more important part, how-
ever, of this process is subconscious,
visceral function and mentality being
alike more powerfully affected by the
assaults of protopathic nerve waves be-
low the level of consciousness, in a way
comparable to the greater actinic power
of waves beyond the violet end of the
spectrum.

Excitants of the protopathic system
may, however, affect epicritic nervous
structures at the same time with distinct
localizing pains as a result.

Protopathic irritation as it increases in
intensity does not always cause greater
pain. As a concrete example, dementia
precox caused by dental impaction has
almost the clearness of a laboratory
experiment, as in it the severest symp-
toms are set up by the simplest irri-
tant. Pains may be from beginning to

Subconscious Sensory Reflexes 59

end quite lacking. Even the dull ache
of protopathic irritation may be absent
in the limbs, and salient features, such
results of subconscious nerve-storms as
the overpowering desire to escape, tear-
ing out of hair, rocking to and fro, and
continual moaning, are the symptoms
attracting attention. When questioned
these patients often deny any pain or
discomfort whatever. Such actions, how-
ever, often follow the lines of referred
pains and are not only significant of
irritation but have a distinct localizing
value.

In discussing the mode of action of the
sensory system it is necessary as far as
possible to consider pain as a valuable
but rare indication; other sensory phe-
nomena are obscure but common. The
protopathic system as it exists in the
more primitive forms of animal life is
direct in its reactions. Motion follows
directly on the stimulus. Epicritic func-
tion and thought do not supplant but
are superimposed on the earlier forms of
reflex and automatic reaction. They

60 Insomnia and Nerve Strain

are switched in on the lower systems
as a distinct afterthought and a protec-
tive mechanism which in man only par-
tially replaces the lower ones.

Consciousness is in full relation with
epicritic sensibility. We are adapted
to know the outside world clearly, and
ourselves as fountains of vague emotion
and organs dimly perceived. The parts
of our body clearly apprehended are not,
our inner selves but our outer lines of
communication with the environment.
The organ of knowing is a thing apart.
It is a protective mechanism of wider
range, but more a matter of cognition
and less of vitality.

REFERENCE OF SUBCONSCIOUS PAINS. —
The dominant ego is usually a mani-
festation of subconscious nerve force.
Some of the most marked and typical
examples of such subconscious domina-
tion are found in dementia precox.

When irritation at the periphery causes
a continuous current of nerve-waste from
the basal ganglia lines of least resistance

Subconscious Sensory Reflexes 61

are occasionally set up from some ad-
jacent sensory region, and the resulting
discharge from that group of cells is
apprehended as a pain, a feeling of op-
pression, or a vague distress. As neural-
gia, headache, pressure at the nape of
the neck, and other like sensory mani-
festations they are frequent in the psy-
choses, especially in melancholia and
dementia precox. When intense they
may be withdrawn from consciousness.
Protective movements persist, however,
as reflex or automatic actions of the
kind previously mentioned. This oc-
curred as a typical instance in Case 17
of the present series.

One patient seen recently was pro-
foundly melancholy for six or eight
years, suicidal, and for the greater part
of the time speechless. By continual
effort the patient had pushed the upper
front teeth backward at an angle of
about forty-five degrees from the vertical.
In this patient both upper and lower
third molars were impacted on the left
side.

62 Insomnia and Nerve Strain

In another patient the subject of
violent attacks of homicidal melancholia
for the last twenty-five years and now
for two years confined in one of the
State Hospitals, the upper front teeth
have been continually picked at with a
pin through their whole length to the
ends of the roots and so persistently
that holes have been picked quite through
them. The left second molar tooth has
been picked out until it is nothing
but a shell. Impacted against this
second molar tooth was a third molar,
and no other molar teeth have been
picked out except the one against which
the impaction has taken place. When
pain occurs as the result of the impaction
of upper third molar teeth it is often in
the adjacent second molars and runs
forward along the jaw occurring in the
front teeth. This patient denied pain
in the teeth but picked at them with a
dreamy faraway look as if the process
gave her relief.

In a case of violent hebephrenia of six

Atavistic Symptoms 63

or seven years' standing with the patient
already somewhat demented, there has
been in addition to beating the head
against the wall and thrusting pins into
the flesh a tearing out of the hair all over
the head, especially over the left parietal
region. This patient had an impaction
of the left upper third molar tooth.

The occurrence of these subconscious
sensory reflexes is most significant.
Such acts furnish the dramatic element
of insanity in the ordinary idea of the
madhouse, although they may be quite
lacking in cases of profound irritation.
When present they have a distinct
localizing value.

ATAVISTIC SYMPTOMS

PROTECTIVE FLIGHT. — When a cater-
pillar is touched it doesn't stop to look
at the threatening hand but crawls away
with tumultuous steps as if each segment
were imbued with an especial and distinct
desire to escape. In dementia precox

64 Insomnia and Nerve Strain

the impulse to wander is an analogous
phenomenon, not the presentation of a
desire in thought but the vague compul-
sion of a feeling coming from an irritated
periphery, a feeling of unrest that per-
vades the emotional field and in its sever-
est form abstracts the mind from normal
sentiment and intellectual activity.

CATALEPSY. — Among the most striking
symptoms of the psychoses, especially in
severe cases of melancholia and demen-
tia precox, are motor phenomena known
as catalepsy and waxy rigidity. These
rigid conditions are in no sense voluntary.
Patients have been known to remain in
the same position in a state of muscular
tension for two or three years without
themselves making any change. Such
a feat is quite beyond the power of voli-
tion, and it may be doubted whether the
cortical centres are capable of such pro-
longed effort even under the domination
of the most powerful stimuli.

Protective rigidities of this kind are
found in abundance among the lower

Atavistic Symptoms 65

animals. Many insects seek to escape
notice by rigid simulation of twigs and
other inanimate structures. The truly
cataleptic rigidity of the ordinary
walking-stick and mobile rigidity of the
praying mantis are evoked by protopathic
stimulation. Some higher animals such
as hares and deer are quiet so long as
they think that they are unseen, and
when it is obvious that they are discov-
ered seek escape by protective flight.

The two most powerful emotions that
come to the lower animals are the earliest
prototype of fear and the desire for food.
The reactions of the protopathic system
to fear are seen in the rigidity as well as
in the protective flight of the frightened
hare, ferocity in the mobile rigidity of
the mantis and the rush of the leopard.
Physical manifestations of such emotions
are present in the psychoses even when
the emotions themselves are absent.

FUGUES. — The longer and more fully
developed examples of protective flight
are called fugues. They are essentially

66 Insomnia and Nerve Strain

irritative in origin and are especially apt
to be evoked as are reflex pains by atmos-
pheric conditions. They occur also in
the lower animals, horses and cattle some-
times being known to drift for hundreds
of miles before an oncoming storm.

Protective flight, fugues, and rigidity
then as they occur in the psychoses may
be considered as analogues of the same
phenomena in the lower animals, and,
as direct products of the protopathic
system, should be differentiated from the
motor results of delusions and other
mental processes.

DERANGEMENTS OF FORMAL
THOUGHT

DELUSIONS. — Of the symptoms of the
psychoses, delusions are the most fortuit-
ous. Their trend and existence depend
more on the acquired than on the
original portion of the apparatus of
mentality, and in the milder cases they
are in much greater degree subject to
circumstance and environment than are

Derangements of Formal Thought 67

the physical symptoms. The study of
lycanthropy, folie a deux and in fact of
almost any individual case shows that
delusions like normal ideas are simply
the attempts of the mind at interpreta-
tion of the perceptual material at hand-
Ideas in the insane as in the sane take
color continually from the inflowing per-
ceptual currents, percepts of nerves of
special sense blending with the mental
content and being informed and colored
by percept, sensation, and emotion from
the viscera. Delusions are thus elabora-
tions and effects of the lesion by
indirection, not vital and scarcely integral
parts of the disease-picture. In fact the
solution of most of the problems pre-
sented by the psychoses lies in the study
of the lower-level phenomena where
brain and sympathetic system meet, and
where it is doubtful whether one has
to deal with mind at all as present in
consciousness.

IDEATED SENSATIONS. — Many delusions
may be considered as ideated sensations of

68 Insomnia and Nerve Strain

touch, a phrase and idea borrowed from
that most suggestive of art-critics Bern-
hard Berenson. In his recent book
North Italian Painters of the Renaissance
he gives a re*sum6 of his earlier views on
the sensory implications of Giotto's paint-
ings important to the student of psychic
values in relation to percepts of special
sense as translated into terms of mind
and emotion.

ORIGIN OF DELUSIONS. — The mode of
genesis of delusions in the psychoses will
be apparent on consideration of proto-
pathic influence on thought in general.

Thought is normally subject to volition
as are speech and movements of the
limbs, but is more mobile and elusive.
At times with an inertia requiring much
effort to overcome, sometimes, as for
instance in insomnia, its near congener,
mania, and many other conditions, it
has compelling power practically irresist-
ible. This is the case during protopathic
stimulation, produced either physically
or by means of ideated sensations. The

Derangements of Formal Thought 69

result is thus identical whether from
an impacted tooth, the ingestion of
alcohol or what is called a stimulating
environment, music, brilliant conversa-
tion or other like factor of emotion. Pro-
topathic excitation, however, is capable
when transmitted into other channels,
of drawing attention and consciousness
away from ordinary thought, impulsion
being to certain limited fields, as for
instance depressive memories. In an
overwhelming tide of subconscious activ-
ity higher mentality may be submerged.
This latter condition is one of pseudo-
dementia.

Under protopathic stimulation senti-
ment and fancy are often quickened and
thought finds readier expression than
is usual. The effect on mentality may
be desirable throughout the whole range
of feeling. Whether formal thought is
often thus stimulated is doubtful. That
it may be much impaired even in the
early stages of stimulation is certain.
These circumstances of emotional and
sensory domination over and weakening

70 Insomnia and Nerve Strain

of formal thought are favorable to the
growth of delusions which are common
phenomena in the sane, and in protopathic
insanity are not neomorphic but attempts
at interpretation of endogenous feelings
and emotions.

Thought then may be stimulated,
weakened, or perverted by protopathic
stimulation. Diversity of result in this
domain as in those of sensation, motion,
and emotion is not from inherent differ-
ence between the pathologic processes
but is due to selective transmission of
the resulting nervous discharge through
various paths of least resistance.

INDUCTIVE INHIBITION

ANESTHESIA. — We are now ready to
discuss the numbing of ordinary sensi-
bility amounting to practical anesthesia
which is so striking a feature of the
worst cases alike of mania, melancholia,
and dementia precox.

We may observe as a preliminary
consideration that although epicritic sen-

Inductive Inhibition 71

sation in the skin overbalances proto-
pathic and is normally more vividly
present in consciousness the protopathic
system predominates throughout the
body as a whole in size and vigor of
action as well as in importance.

The infant is born practically devoid
of epicritic function but soon attains to
a fair amount of localizing information
gained from all of the epicritic terminals.
Protopathic information on the other
hand remains incomplete throughout life,
but may be added to from time to time.
There is more individual variation in
protopathic than in epicritic sensibility
with regard to completeness, special
viscera giving reactions of pain in some
individuals and none at all in others.

The phenomenon observed by Head of
excessive pain produced by stimulating
skin supplied by protopathic but not by
epicritic fibres may be explained by
supposing that currents in the nerve-
fibres are governed by the same laws
with electric currents under the same
circumstances.

72 Insomnia and Nerve Strain

Such currents when passing in insulated
wires generate in wires running parallel
to them a current in the opposite direction
on each closure of the circuit and a
weaker current in the same direction on
the opening of the circuit, so that the
effect of an interrupted current is the
increase of electric activity in the opposite
direction in wires parallel to it. Nerve-
force is supposed to flow in all three
sensory systems in the same direction,
that is centripetally ; if so the effect of
the action of any one system is to dimin-
ish the activity of each of the others.
Thus each system is in a way regulated
by the others.

CONVULSIVE SEIZURES AND
CHOREIC SPASM

MECHANISM OF SENSATION. — To un-
derstand even approximately the relation
of structure with function in the nervous
system a comparison is necessary, and
only one is in any degree adequate, the
time-honored one of an electric apparatus.

Convulsive Seizures 73

Let us suppose then a battery of cells
in the central ganglia and sensory nerve-
fibres as wires coming in from the
periphery. These countless distal signal-
stations must be provided each with a
rheostat to account for the curious
phenomena of irritation. Every one famil-
iar with the water rheostat will realize
that the carbon plates which when
approximated allow the current to pass
may easily be duplicates of the sensory
end-bulbs; this is an explanation of
the gradually increasing discharge in the
basal ganglion cells determined by rising
peripheral irritation. In fact the very
circumstances and means of irritation
are such as to suggest a similar or
identical action. As an example a mod-
erate poison swells the terminals or
otherwise bridges the gap and allows
the current to pass; or a severe toxin
or heat which besides the swelling causes
corrosion and thus closure of the circuit;
or worst of all simple mechanical
pressure, which as it persists and
increases day by day never breaks but

74 Insomnia and Nerve Strain

pushes the plates relentlessly together
until the battery is fairly short-circuited ;
thus from renal torsion or dental impac-
tion comes the terrible outpouring of
energy in this or the other part of the
ganglionic network as emotion, motion,
or sensation, and then exhaustion which
persists until pressure is relieved or
death ensues.

A ganglion cell like a galvanic cell is
active in inverse proportion to the resist-
ance in the circuit, and the current set
up by partial or complete closure at the
periphery selects in passing in and from
the ganglia lines of least resistance in
both fibre and cell.

The theory of the neuron as a working
hypothesis is here adopted, together with
the generally received notions of the
cortex as the principal seat of conscious-
ness, and the basal ganglia, here used to
include the spinal cord, as the location
of reflex and subconscious motor and
sensory nervous activity.

LOCATION OF CONSCIOUSNESS. — In or-

Convulsive Seizures 75

der to an understanding of the reactions
of the central and peripheral nervous
mechanism to mechanical and toxic stim-
uli a brief consideration will be necessary
of consciousness in its relation to the
ganglionic masses, and of the familiar
sensory and motor reactions to organic
disease of the brain as well as to toxic
agents.

It is generally agreed that conscious-
ness is not a function supplied by a
cerebral centre but is an attribute of the
whole cortex, varying in intensity at
different times and in different individuals
and subject to a limited high-tension
phenomenon variable through the whole
field of consciousness, to some extent
subject to volition, called attention.
While attention is variable the com-
paratively mild and diffuse phenomena
of consciousness go on so far as is known
from birth to death, conditioned only
on an activity of the cells in which they
reside. When the activity of any of these
cells is increased by stimuli from without
or from other parts of the brain, con-

76 Insomnia and Nerve Strain

sciousness becomes more intense, until
a point is reached where attention is
involuntary and compulsive.

THE CORTEX NEVER DIRECTLY STIMU-
LATED.— Consciousness being thus directly
variable with the activity of the cells we
may inquire whether their phenomena
may be produced by direct irritation.
The fundamental proposition may be
laid down that all stimulant action in the
nervous system whether by mechanical
agents, toxins, or organic disease is exerted
on the basal ganglionic masses or per-
ipheral nerve structures, never on the
cortical centres. As applied to the
neuro-psychoses it must at present suffice
to examine the phenomena of epilepsy
and chorea, in order to compare them
in mode and place of origin with the
psychoses under discussion.

The evidence is conclusive that the
cortex may be experimentally cut, lacer-
ated, and subjected to chemical irritation
to any extent without being stimulated

Convulsive Seizures 77

to activity of either its motor o,r sensory
functions or to consciousness. This is
also abundantly evident at operations on
the cortex, the electric current being the
only apparent stimulant, though irritants
are many.

EPILEPTIFORM CONVULSIONS. — The
phenomena of the irritant action of brain
tumors and other lesions are more com-
plex. As a result of cortical disease
convulsions are set up, sometimes of the
common epileptic type, sometimes begin-
ning in one group of muscles and spreading
to others until they become general. A
sensory aura is held to indicate an
involvement of the sensory centres, the
discharge beginning in the sensory cortex
and spreading to the motor area.

That the centres of conscious sensory
activity in the cortex are stirred to
exaggerated action one after the other
with the patient in profound unconscious-
ness is as near as possible to the unthink-
able. There is here no question of
exhaustion from over-stimulation, uncon-

78 Insomnia and Nerve Strain

sciousness usually dates from the begin-
ning of the attack and the centres
resume their function a few moments
after its cessation.

No SENSORY OR PSYCHIC EPILEPSY. —
It is further true that there is neither
sensory nor psychic epileptic spasm
corresponding to the motor convulsion.
Such a paroxysm may be easily imagined.
It would necessarily be terrible pain either
involving successively one part after
another of the sensory field, in fact a
sensory Jacksonian spasm, or like a
general convulsion, a sudden universal
outburst. Instead of such a storm there
is a light breeze, an aura, consisting of
a tingling feeling, a flash before the eyes or
other short-lived phenomenon ushering
in a motor attack.

So-called psychic equivalents are in
no sense epileptic outbursts of mentality.
So far from being increments of intellec-
tual energy they are characterized by
diminution of consciousness much like
that of ordinary sleep, as is indicated

Convulsive Seizures 79

in their usual name, dream-states. In
other words they are memories not
evoked by the disease but modified by
a partial withdrawal of consciousness.

The same reasoning has even more
significance when applied to the centres
for the storage of visual, auditory, and
other memories. In the adult, memories
are innumerable as the sea-sands, and
their revival is only conceivable as occur-
ring in consciousness and varying with
consciousness. If a discharge were to
sweep through this preponderating por-
tion of the cortical gray, gathering force
as it passed from ganglion to ganglion
the resultant nerve-storm with its accom-
panying agony of heightened conscious-
ness would compare with no convulsion
of insentient nature but the awful
majesty of the tornado. There is for-
tunately in human experience no such
event as this. The brief sensory phenom-
ena that usher in an attack are only
such signals as may be sent in a moment
and then the wires are down in the storm.

8o Insomnia and Nerve Strain

MOTOR CONVULSIONS NEVER CORTICAL.
— The consideration of motor phenomena
in epilepsy is equally conclusive. Even
a superficial comparison of the epileptic
movements with action caused by normal
discharge in the motor area of the cortex,
shows the widest possible difference in
quality. Epileptic spasm is not accom-
panied by nor caused by volition, it is
not volitional in kind, being far removed
from the delicate and complex move-
ments due to activity in the co-ordinat-
ing centres, and when general and severe
it is always accompanied by profound
unconsciousness.

That the great voluntary co-ordinating
centres in the cortex which energize the
muscles are not roused to involuntary,
unconscious, and inco-ordinate spasm is
somewhat axiomatic in its obviousness.

Significant also is the fact that the
speech-centre is never involved in con-
vulsion and that disease of this centre
itself never causes its epileptic discharge.

LESSER ATTACKS NOT CORTICAL. — In

Convulsive Seizures 81

the case of epilepsy these facts find
confirmation in the development of de-
mentia due to exhaustion and finally
permanent loss of function from over-
action in the attacks. This loss of
function finds expression mainly if not
entirely in the subconscious apparatus
of the intellect, and especially in the
finer emotional adjustments which are of
the part of the mental output called
character. This corresponds with the
fact that the so-called lesser attacks
are the more destructive of mentality;
these may be explosions of energy running
like lightning through the subconscious
intellectual apparatus at the base of the
brain, a part of the nerve mechanism
proverbial for its quickness of action,
and meanwhile drowning consciousness,
as is always the tendency of intense
protopathic action.

CHOREA. — It may seem that as the cor-
tex is thus shown to be capable of stimula-
tion only by signals of nerve force or its
analogue in the outer world, electricity,

82 Insomnia and Nerve Strain

cortical paroxysms might be set up by
excessive stimuli coming from the sensory
system. In fact this does occur. If we
think of the necessary condition of
manifestation of such paroxysms, it is
evident that they must be conscious
and co-ordinate, and the name applied
to them is chorea. The closely allied
habit spasms are often caused by peri-
pheral irritants, and as choreic spasms
are evidently cortical and cannot be
caused by direct toxic action, the toxic
locus morbi must be in the basal ganglia
or periphery.

The sensory and mental phenomena oc-
curring in chorea minor and its analogy with
habit spasms make a protopathic origin
probable. Organic cerebral disease asso-
ciated with choreic spasm is usually situ-
ated in or near the great basal ganglia.

MECHANISM OF EPILEPSY FROM CORTI-
CAL DISEASE. — All these phenomena lend
color to the belief that in the basal
ganglia the afferent sensory fibres are
connected with the motor centres, as in

Convulsive Seizures 83

effect they are shown to be by reflex
phenomena, and that the motor centres
are connected in series. Such an arrange-
ment is necessary for ordinary combined
muscular action, much of which must be
provided for in these lower centres.
The sensory centres on the other hand
are not interconnected, one sense-impres-
sion rarely setting up a heterogeneous
percept and such abnormal percepts
never occurring in series. Such an ar-
rangement furnishes the explanation of
the single sensory and multiple motor
discharge as a response to overstimula-
tion. The explanation of so-called corti-
cal epilepsy is in the degenerative process
which is invariably downward from cor-
tical disease. Fibres in both motor and
sensory systems run in both directions
and when degeneration sets up such irri-
tation in the basal ganglia as to cause an
epileptic discharge, it naturally begins
in the structures corresponding to the
cortical centres.

To summarize: — Epileptiform convul-
sions invariably consist in discharge of

84 Insomnia and Nerve Strain

the basal ganglionic centres, and are
determined in three ways: by irritation
essentially degenerative downward from
the cortex; by protopathic overstimula-
tion up from the periphery; by toxins
or disease acting on the basal ganglia
direct. The two latter classes constitute
the disease known as epilepsy, except
for cases in which the cause is known,
as for instance in those of renal origin.

VASCULAR POTENTIAL

THE VASO-NEURAL CIRCUIT. — When
galvanic currents are applied to periph-
eral nerves it is found that centripetal
currents increase and centrifugal currents
dimmish the activity of the sensory
fibres. It follows that the normal sensory
nerve currents are centripetal, and with
equal certainty that the sensory is a one-
way system. This means that with the
battery in the central ganglia the periph-
eral fibre is connected with the negative
pole of the cell, and the circuit must be
completed through other tissues. As

Vascular Potential 85

for the sensory and other cells not
connecting with the periphery but with
different parts of the brain there is
every reason to think that they are run
on the same system.

It is impossible that grounding should
take place normally through the skin.
The skin is often dry, practically a non-
conductor, and usually in contact with
the ground only through the soles of the
feet.

The same reasoning applies with still
greater force to the ganglion cells in the
brain. The skull, skin, and hair are
practically absolute insulators. Only one
alternative remains. The circuit must
be completed by way of the blood-
stream.

MOTOR NERVE-CURRENTS ARE CENTRI-
PETAL. — In the motor system it has
usually been taken for granted that the
current flows from centre to periphery,
that is centrifugally. We know, however,
that normally cathodal closure contrac-
tion is greater than anodal closure

86 Insomnia and Nerve Strain

contraction, that is the normal muscle
reacts more strongly to the negative
than to the positive pole of the galvanic
current. This proves that the current
of normal nerve-force in the motor
fibres is negative, that is to say the
motor like the sensory fibres are connected
with the negative pole of the nerve-cells,
and the positive current is in the blood-
stream.

INHIBITION BY VASCULAR POTENTIAL.
— Important conclusions follow. There
is here an added reason for the balance
between the epicritic and the protopathic
systems in the skin. A stimulus in
reaching the protopathic terminals from
without inevitably excites the epicritic
system. Both systems discharge their
positive currents into the same blood-
stream, and each positive current escapes
into the blood less readily because charged
from the other system. The same state
of things obtains in the brain. Motor
and sensory cells alike discharge their
positive current in the blood, and unusual

Vascular Potential 87

activity in any group of cells inhibits
the activity of all the others by charging
the blood-stream positively.

This makes possible a clearer concept
of the self -limiting mechanism of pain.
The sensory cells of the cortex are small
and of comparatively low potential. High
vaso-electric tension makes impossible
their normal discharge into the vessels.
When a stimulus, a burn for example,
occurs over a small area of the skin the
positive blood-charge is raised, but not
enough to interfere with cellular action.
If a large surface is burned, electric
tension is raised to what may be called
the anesthesia point, or with still greater
tension unconsciousness may be caused.

It is difficult, in fact impossible, to
carry on several lines of thought at the
same time, although thought and speech
are consistent with moderate activity
in the motor centres of the arms and legs
which discharge into the blood at some
distance. It is doubtful, however, whether
any one can carry on a sustained and

88 Insomnia and Nerve Strain

difficult logical process while running at
top speed. Inhibition by highly charged
blood-currents finds its most striking
example in the epileptic paroxysm, in
which severe general convulsions so in-
crease electric tension in the blood as
completely to inhibit the sensory centres,
and unconsciousness is the invariable
result.

PARALYSIS BY ANEMIA. — When the
circulation is suddenly cut off from any
part of the brain tissue by thrombus or
embolism or in any other way the gang-
lion cells in the affected area instantly
cease to act. This is not to be explained
by the cutting off of their nutritional
supply, which would begin to affect
function after hours or days. Ganglion
cells are set in a rich net-work of small
blood-vessels. When circulation is cut
off the blood at once leaves the small
vessels and settles in the veins, the cir-
cuit is broken, and function ceases in-
stantly, to be renewed if at all when
circulation is re-established.

Vascular Potential 89

PARALYSING EFFECT OF COLD. — The
numbing effect of cold on nervous activity
also here finds explanation. Ganglion
cells and nerve fibres like the galvanic
battery should work approximately as
well when cold, which excites but never
directly soothes nerve terminals. We find
accordingly that cold as it stimulates
the epicritic and protopathic end-organs
acts as a tonic, and nervous energy is in-
creased. When, however, it penetrates
deeply enough to reach the vessels and so
stimulate them contraction results, the
part becomes bloodless, and the ordinary
sensory rheostats are deprived of their
connections with the main blood stream.
Hence anesthesia results.

When the whole body is chilled for a
sufficient time to lower the temperature
of the blood and stimulate the small
vessels about the central ganglion cells,
they contract and the circuit is again
broken, and anesthesia, unconsciousness,
and finally paralysis and death ensue.

VASCULAR POTENTIAL AS A CAUSE OF

90 Insomnia and Nerve Strain

FATIGUE. — Fatigue is a phenomenon that
may well occasionally bear an electric,
not entirely a toxic, interpretation. After
long ganglionic activity of any kind,
sensory, motor, or mental, the blood-
stream is highly charged positively. It
requires more vigorous negative discharge
to overcome the resistance. A bath,
especially a hot bath with a following
cold shock and reflux of blood to the
skin, or massage, or the neutralizing
and stimulating negative galvanic current,
lowers positive vaso-electric tension and
new energy may be tapped from the
cells without undue effort.

EFFECT ON PLAIN MUSCLE. — While
striped or voluntary muscle is stimulated
more actively by the negative pole,
plain or unstriped muscle, as it exists
in the blood-vessels, stomach, intestines,
and other viscera, responds more readily
to the positive pole. The phenomena of
heart-action make it probable that this
is also true of the heart muscle, which in
structure seems to be half-way between

Vascular Potential 91

the other two kinds of muscular tissue.
The tendency then of a high vascular
potential is to increase the activity of
plain muscle throughout the body.

When a voluntary muscle is entirely
severed from its connection with the
cerebro-spinal system, it loses its tone,
is reduced to the condition of a plain
muscle, and gives corresponding reactions
— that is, it reacts more vigorously to the
positive pole and with a slow worm-like
contraction. This, however, does not
take place until about a week after the
cutting of the nerve-supply — that is, until
the degenerative process has had time
to creep down and destroy the muscular
end-plate.

Increased heart-action then and arterial
contraction are set up by muscular
exertion, emotion, excessive pain, or toxic
irritation causing increase of vascular
potential.

The effects of sudden raising of the
potential of the blood-current on viscera
supplied with unstriped muscle are well
known. Thus increased gastric and intes-

92 Insomnia and Nerve Strain

tinal activity, with vomiting or diarrhea,
may be caused by emotion or pain, and
action of the bladder may be induced in
the same way.

EFFECT ON THE IRIS. — A sensitive index
of electric tension in the vessels, although
not an uncomplicated one, is furnished
by the iris supplied by radiating — that is,
dilating — unstriped muscular fibres. The
nearness of the eye to the brain gives cere-
bral activity a specially close connection
with the pupillary reaction. During
sleep vaso-electric tension is at its lowest
and the pupil is contracted. Even
slight mental energy dilates it a little.
During waking hours it is of medium
width, unless impact of light on the
retina or toxic agents have affected it.
It is dilated by unusual emotion or
general physical exertion, and is widely
dilated during the epileptic paroxysm.

VASCULAR POTENTIAL IN ACUTE SHOCK.
— Crile's brilliant researches have shown

Vascular Potential 93

that shock is essentially a rapid exhaus-
tion of the forces of the nerve centres.
Acute shock may be denned as a sudden
intense disturbance of the vaso-neural
electric circuit. It may be caused by
grounding the positive current in the
blood-vessels, or by a short circuit intro-
duced between vessels and nerves. From
what has been said with regard to the
reactions of the vascular system to the
electric state of the blood, it must be
evident that the calibre of the vessels
will differ with the varying electric ten-
sion in these conditions.

The painful results of the short circuit
are recognized in the popular dread of
the knife as compared with the bullet.
The slash is only painless when quick as
light.

Shock might be largely avoided by
insulated as well as by bloodless surgery ;
and the shock of bloody surgery is the
shock, not of denutrition, but of low-
ered potential and a broken vaso-neural
circuit.

94 Insomnia and Nerve Strain

MECHANISM OF THE VASO-
NEURAL CIRCUIT

LOCATION OF CLOSURE OF THE CIRCUIT.
— To form an adequate idea of the com-
plete mechanism of the vaso-neural circuit,
it is necessary to consider ganglion cells
with reference to the points of normal and
abnormal closure. This has already been
done in part with regard to the sensory
system, the end -organs being rheostats for
graduated closure of the sensory circuit,
thus causing ganglionic discharge propor-
tional to the amount of the irritation.

It is impossible that the motor circuit
should be closed at the muscle. The
motor ganglion cell is discharged as the
result of a stimulus imparted to it in the
central organs by a nerve fibre com-
municating with it indirectly. The cor-
tical cells cannot be directly stimulated.
They may be destroyed by any irritant
that causes an internal short circuit. The
only available explanation of the failure of
direct stimulation is that the normal break
in their circuit is in the basal ganglia.

Vaso-Neural Circuit 95

MOTILITY OF GLIA CELLS. — The sub-
stance intervening between the inosculat-
ing processes constituting make and break
is glia tissue. The glia cells, then, inter-
vening between the dendrites of the motor
cell and the vessels, or between inosculat-
ing processes of fibre and cell, respond to a
stimulus from a sensory cell by a contrac-
tion which narrows and elongates them
like an earthworm, and the connection is
thus made. This endows the sensory sys-
tem with motor functions exerted on
the cells of the glia.

The fact that cells cannot be stimu-
lated in the cortex makes consecutive
combined movements impossible of cor-
tical elaboration. On the other hand,
simultaneous elaborations may be corti-
cal, a single impulse from the base
being diffused among a number of cells
along lines of acquired least resistance
of the intermediary glia cells.

The motility of the glia cells, then, like
that of muscular fibre, is dependent on
use, and ready and vigorous response
to stimulation is in proportion to the

96 Insomnia and Nerve Strain

amount of their previous exercise, espe-
cially recent exercise. Functional nervous
disease owes what of permanence it
possesses, apart from the persistence of
the lesion, to over-developed glia cells
constituting abnormal conducting paths,
the glia cells resuming their normal size
and activity gradually by rest after
removal of irritation.

PAIN NOT CORTICAL. — The fact that
sensory cells cannot be stimulated in the
cortex makes it certain that the stimulant
closure of their circuit occurs lower
down. This enables us to locate the
function of pain. If it were registered
in the cortex, closure of the circuit by
basal disease would be excruciating agony.
On the contrary, disease in that region is
attended by numbness, tingling, and local-
izing feelings. Like emotion, pain is prob-
ably felt in the basal ganglia, and the point
of its genesis by stimulation is lower down.

GANGLION CELLS NOWHERE DIRECTLY
STIMULATED. — This leads us to the
broader statement that ganglion cells

Vaso-Neural Circuit 97

can never be directly stimulated either
mechanically, chemically, or electrically.
An electric current may be sent from a
motor cell along the axis-cylinder process.
Easily leaping the glia cell to the lower
neuron, it stimulates the muscle. The
effect of irritation in either of these
three kinds on the ganglion-cell itself is an
internal short circuit. The result is
irritation with so-called sedation and
final exhaustion.

The reason for the impossibility of
discharging a ganglion cell by the direct
application of electricity will be made
clearer by the following consideration.
Suppose an ordinary galvanic cell with
the carbon and zinc attached to wires
with terminations a sixteenth of an inch
from each other and at some distance from
the cell. Functional discharge of the
cell is possible only by the introduction
of a conductor between the ends of the
wires. If the function of the system is to
ring a bell on one wire situated on a loop
beyond the break in the circuit, a connec-
tion made between the wires above the

98 Insomnia and Nerve Strain

break will short-circuit the cell. Direct
connection in the cell between carbon
and zinc will result in an internal short-
circuit. If now the current from a
dynamo be applied to the cell or to
either of the wires, as a result the bell
may be rung, the gap being ineffective
for a current of higher potential. The
only possible effect on the cell itself is a
short-circuit.

The cortex, then, so far as it is known,
is a power plant tributary to the main
electric system of the base. It consists
of batteries and storage batteries actuated
entirely from below.

NUTRITION AND VITALITY

TROPHIC CONTROL BY VASCULAR
POTENTIAL. — That vascular potential
regulates trophic processes of the body
in general is evident on the following
consideration.

When a membrane is interposed be-
tween two compartments filled with fluid,
with a negative electrode in one and a

Nutrition and Vitality 99

positive in the other compartment, while
the current passes there is set up a flow
of fluid through the membrane from the
positive to the negative pole. These con-
ditions are satisfied by both nerve cells
and glandular cells all over the body.
The limiting cell membrane separates
the contained protoplasm from the posi-
tively charged blood stream. As electric
tension rises, osmosis is more active; the
whole glandular system is thus electri-
cally stimulated by muscular or mental
activity or emotion, in degrees varying
inversely with the distance of the gland
from the active nerve cells, and directly
with the amount of their activity. Thus
while nutritional and metabolic processes
are under the direct electrical control of
the nerve centres through the blood
stream, the ganglion cells furnish alike
the current of their functional activity
and their own nutrition.

The gland cell, then, in its proper
functional activity is an electro-chemic
diffusion apparatus subject to control
from a distance. Cell protoplasm

ioo Insomnia and Nerve Strain

apparently furnishes the negative elec-
tricity of the circuit, the nucleus being
a positive element. This may well be
the primordial apparatus of glandular
activity, supplemented in the higher
animals by vascular potential.

GENERAL CONTROL OF NUTRITIVE PRO-
CESSES.— What has been said with regard
to glandular structures applies with equal
force to the cells of the other tissues of
the body. Thus nutritive processes vary
directly with the general nervous activity
of the moment, and with the richness of
capillary supply, and inversely with the
distance from the centres of greatest
electric activity.

In the nervous system the protoplasmic
processes are so numerous as to suggest
that they provide for the nourishment
of the ganglion cell, as well as closure of
the current with the blood stream. Dur-
ing activity, osmosis is from within out-
ward, the cell potential being necessarily
greater than that of the blood stream.
The result is the shrunken cell of fatigue.

Nutrition and Vitality 101

During rest, the potential of the cell is
lower and osmosis is from without inward.

NUTRITION OF MUSCLE. — The problem
of nourishment is somewhat different
with regard to the three varieties of mus-
cular fibre. The primitive muscle is the
plain or unstriped variety. This is
sluggish in movement, actuated by the
positive charge of the blood stream, and
draws its nourishment from the blood
partly by its sluggish movements, partly
by electric osmosis as do the glandular
structures.

The heart is much more vigorous, is
active from birth to death, and needs
the maximum of nourishment, which is
provided for by its own active movements,
aided by its more permeable striped
structure and by electric osmosis as well.

Voluntary muscle is striped to allow
the maximum of nourishment during
the activity of the muscle cell. If, how-
ever, osmosis went on uninterruptedly
during rest, over-nourishment would be
the result. The end-plate of the nerve,

102 Insomnia and Nerve Strain

however, is on the outside of the muscle
fibre and vaso-electric connection is with
the interior of the cell. This reduces
the difference between external and in-
ternal potentials to zero, and explains
the rapid retrogressive changes from
disuse.

When a peripheral nerve is cut, vas-
cular potential falls in the supplied area
either motor or sensory. The part is
practically cut out of the electric sphere
of influence of the body generally, and,
as is well known, trophic changes result
in all of the tissues.

CELL POTENTIAL IN EVOLUTION

A consideration of vascular potential in
its developmental relations may be of value,
as a basis for further investigation.

In unicellular organisms specialization
has just begun, and is comparative with
non-vital substances. The power of as-
similation, of sensitiveness to impact,
and of comparatively purposive move-
ment are acquisitions. The specific dif-

Cell Potential in Evolution 103

ference, however, from non- vital matter
is the ability to maintain nutritional in-
terchange with environmental substances
by means of a difference between in-
tracellular and extracellular potential.
This is made possible by electric activity
between nuclear and extra-nuclear proto-
plasm, the evolution of the cell with its
nucleus being the anatomic attribute,
and electric osmosis the physiologic at-
tribute of vitality in primitive organisms.

Physical osmosis by capillarity and by
contractile movements, and osmosis by
differences of density are non-specific
acquired powers.

With the acquisition on the part of
the cells of more complex animals of
highly specialized powers, in the gland-
ular tissues metabolic power, in plain
muscle contractile power, and so on,
there is in most tissues retention of spe-
cific electric function in the same sense;
that is, the maintenance in cell proto-
plasm of negative potential as compared
with extra-cellular and intra-nuclear posi-
tive potential.

104 Insomnia and Nerve Strain

In the evolution of the ganglion-cell
and the correlated striped-muscle tissue,
a specific difference from lower grade tis-
sues is introduced.

The structure of the ganglion cell indi-
cates the electric continuity of the axis-
cylinder process with the nucleus, and
of the protoplasmic process with the cell
body. We have already seen that the
axis cylinder is connected with the nega-
tive, and the dendrites with the positive
pole of the cell. This is the reverse of
the formula of polarity of the lower
tissues.

In striped muscle, by the electric con-
nection of the blood stream with the in-
terior of the cell, there is no difference of
potential between cell and blood, and
osmosis is not electric, but only mechan-
ical and chemical.

The specific difference, then, between
ganglion cells and lower cells in general is
in the reversal of polarity ; the distinguish-
ing feature of striped muscle is the neu-
tralizing of polarity.

Nutritive processes go on in ganglion

Epicritic Neuro- Psychoses 105

cells practically only during rest, in
striped muscle practically only during
activity; while in other tissues functional
and nutritive processes are alike practi-
cally continuous, being less active during
sleep only by reason of the lowering of
vascular potential.

Vitality may be said to consist in the
ability of an organism to maintain a dif-
ference of potential sufficient to carry
on nutrition by electric osmosis. It is
a power inherent in most or all cells and
specialized in the ganglion cells.

The conclusion seems warranted that
nerve force and electricity are related
by identity rather than by likeness.

EPICRITIC NEURO-PSYCHOSES

HYSTERIA. — Of the lesions thus far
considered, neuroses and psychoses alike
are primarily lower-level disorders, and
in them the cortex is implicated only
secondarily. There remains one of the
most complex of the functional disor-
ders and one which has long been the

106 Insomnia and Nerve Strain

subject of careful study, namely, hysteria.
Its symptoms, while often disturbances
of vegetative life, concern themselves
about equally with the emotions and with
the perceptive functions and highest
mental activities of the cortex, conscious-
ness, attention, and volition. The short-
est possible statement must here suffice
of the hysteric symptom-complex in its
relations with the nervous mechanism.

The characteristic feature of the hys-
teric symptom-complex lies in the ease
of conjunction and disjunction of the
ganglionic centres, both conscious and
subconscious, together with abnormal
activity of the centres.

It is not necessary to suppose unusual
power on the part of the ganglion cells
themselves. There is rather an unusual
completeness of connection of the vaso-
neural circuit as well as between the
nerve centres, with correspondingly rapid
exhaustion of nervous energy. Volition
and self-consciousness have an undue
share in the abnormal condition, and are
worthy of special consideration.

Epicritic Neuro- Psychoses 107

Self -consciousness is the highest appli-
cation of formal thought to the processes
of ideated sensation and vivified idea,
resulting in cognition of mental per-
sonality, distinguished from physical
identity, as a partly inherent, partly
habitual mode of operation of percept
and thought in a special and delimited
nerve-mechanism.

A voluntary act is one to whose pro-
duction the highest mental functions,
consciousness and formal thought, have
contributed. Volition so far as it exists
within the limits of cognition is a feeling
of freedom of choice and to a greater or
less degree a feeling of effort accompany-
ing certain conscious movements of the
soma, operations of the psyche, and selec-
tive movements of attention.

Certain limitations of the will are sub-
jectively recognized, comprising acts
carried out by the lower motor centres,
thoughts that seem to come into the
mind spontaneously and attention
compelled by sensation overmastering

io8 Insomnia and Nerve Strain

memory and thought. The dominance
of ideated sensation is also subjectively
recognized, either as the spoken word
compelling and determining ganglionic
activity, or the power of circumstance
acting through consequent emotions. It
is this dominance of ideated sensation in
either of its forms that, normally present
in all men, when abnormal in degree is
the essential feature in hysteria.

MOTILITY OF THE GLIA IN HYSTERIA. —

Predisposition to hysteria consists in an
original or acquired ease of disjunction
of certain paths of communication between
cortex and basal ganglia. The hysteric
may thus be capable of mental activity
of high grade, but has an instability
between conscious and unconscious men-
tality. Hysteric symptoms result from
shocks or suggestions breaking the con-
nections just mentioned. It is apparent
that hysteria has affiliations with both
hypnotism and ordinary sleep.

Unusual activity of association between
percepts and memories on the one hand,

Epicritic Neuro- Psychoses 109

and the protopathic system on the other,
brings the hysteric into strong touch with
the wills of others, and the result is a
protopathic system dominated. In the
genius, in whom the power of concentra-
tion is unusually developed, the intrinsic
faculty of formal thought is stronger.

Clinically hysteria may be provisionally
defined as a state of abnormally height-
ened consciousness subject in unusual
degree to abstraction from certain fields
and increased attention to others under
the influence of protopathic and epicritic
forces alike extrinsic and intrinsic. The
diminution and heightening of activity
in the cortex result in nerve currents
which follow the lines of least resistance,
in the higher psycho-motor centres, or
downward to the sensory and emotional
mechanism of the base. Unusual length
and motility of the glia cells such as are
here supposed explain the equal suscep-
tibility of hysteric subjects to psychic
and physical shocks.

It is easy to see that when disjunction
occurs from concussion or from a strong

1 10 Insomnia and Nerve Strain

sensory impression, physical recovery of
the glia may in time be practically
complete, and a mental impression be at
last the means of forcing a current through
the re-established pathway.

Disjunction then in the hysteric may
be a local phenomenon resulting in
anesthesia or paralysis, or approximation
of the mobile glia may result in hyperac-
tivity either motor or sensory. More
general disjunction, especially by hyp-
notic suggestion, may plunge the hysteric
into sleep at times profound, but, like
ordinary sleep, consistent with the main-
tenance of certain communicating paths
and much cortical activity.

I am inclined to class hysteria tenta-
tively as an epicritic disease. Its symp-
toms are largely in the epicritic field,
voluntary convulsions, spurious coma,
and imitative diseases. Its precipi-
tating cause is often epicritic, either
ideated sensation or the spoken word.
Its cause may be protopathic, as the
exciting cause of protopathic disease
may be epicritic.

Prognosis 1 1 1

Hallucinatory insanity and paranoia
are epicritic in manifestation. I have
made no observations in regard to the
location of possible irritants in these
cases. Provisionally they may be classed
as epicritic psychoses.

PROGNOSIS

In the preceding sections we have gone
far by deduction to gain some idea of
nervous interaction. Such considera-
tions are of moment in proportion with
their ultimate bearing on the concrete
phenomena of disease, and hope of cure.

The outlook for recovery from any
disease is in proportion not only with
the chance of spontaneous removal of
irritation and nutritive repair, but with
the possibility of aiding these processes
on a basis of adequate diagnosis.

Among the diseases here set down
there is one that has no single redeeming
feature. Many epileptics have long inter-
vals of normal activity; maniacs have
the joy of their disease; the demented

ii2 Insomnia and Nerve Strain

have at least euphoria, lapsing with
the revolving years into the final mercy,
euthanasia; but a little melancholy is a
little curse and a great melancholy is
torture indescribable. Of this one disease,
subjectively at any rate the worst of all,
it may be said that it is often not only
recoverable but curable, absolutely and
by procedure. This follows from the
many cases of recovery prompt on the
heels of definitive protopathic relief.
Most of these patients are permanently
cured, the earliest of those here set down
being at this writing well for fifteen years
and more.

In regard to mania, indications by
analogy and direct experience supplement
the present recorded cases and indicate
the same result of cure. The same may
be said even of dementia precox.

Patients apparently demented for years,
the cog-wheels of the memory to all
appearance thrown permanently out of
gear, often finally rouse and return to
normal life. Noteworthy is the fact
that most of the patients studied by

Prognosis 113

Kraepelin in his great work on Manic-
depressive Insanity, and scheduled by
him as hopelessly demented, eventually
recovered after many years. The number
of memories in use by an individual
at a given time is almost infinitesimal
compared with those that are inactive.
Attention may be withheld from any
group of memories by the activity of
attention given to another group, or may
be abstracted from the higher memories
entirely, by abnormal activities in the
protopathic structures at the base. That
on the recovery of protopathic health
memory is regained is in accord with
what we know of facts relating to
memory in other conditions.

The number of spontaneous or rather
accidental recoveries recorded from time
to time have been enough to indicate
the possibility of a lesion curable if
found. Significant lesions in abundance
have been already found by skiagraph
in many of the cases here described and
indications of more are to be had for
the seeking. The lesions have been

H4 Insomnia and Nerve Strain

removable, and analogy with the results
attained in other groups of cases beats
a broad path of probability of a success-
ful issue here also, to measures thought-
ful in their adequacy and vigorous in
execution.

Of insomnia it may be said that it is a
symptom, the most tractable of all,
whether it goes hand in hand with mental
aberration or in association with the
mildest indications of the neurosis of
fatigue. This tractability is, however,
absolutely conditioned on removal of
continuing irritations.

The other diseases under consideration
are known to be curable in varying
proportion, the more if their cause is
known.

THERAPY.

The neuro-psychoses are in part toxic
in origin. To understand the symptoms
and the methods of their cure it is
necessary to consider in brief the ration-
ale of the selective action of poisons on

Therapy 115

the nervous system, especially the alco-
hols, ethers, and alkaloids.

DRUG ACTION. — Two striking and
recently observed instances of such
selection are the local anesthetic effect,
which really means the peripheral
anesthetic effect of cocain, and the
comparative actions of the sulfonal
group, practically pure hypnotics, and
of the antipyrin group, practically pure
sedatives of pain.

The effect of the latter group on tem-
perature is too obscure for present con-
sideration and will be ignored. A com-
parison of the developmental reasons for
the differences between their actions and
those of the alcohols and ethers gives a
clue to the location and probable reason
for the location of action of these several
toxic substances.

The lowest animals to develop a heart
with a nervous mechanism of stimulation
were small creatures and soft, penetrable
throughout by the ordinary products of

n6 Insomnia and Nerve Strain

fermentation and decay, alcohols and
ethers. Their life depended on the de-
velopment of nervous tissue resistant to
the sedative action of these substances;
such resistance is not absolute but exists
to a comparatively high degree. Later
respiration was developed, aerial and
aqueous, carried on by a nervous mechan-
ism of somewhat feebler resisting power.
The general protopathic system, the
penalty of whose temporary sedation
is not the instant death of the whole
organism, became endowed with a selec-
tive resistance. The deeply situated
ganglion cells are less resistant to the
sedative action of these omnipresent
poisons. The end-organs, whose useful-
ness lies in their excitability, are stimu-
lated alike by wounds, heat, pressure,
even by these erstwhile toxic sedatives.
The later epicritic system, with its
receiving centres in the cortex and signal-
stations in the skin, presents a curious
deviation from the action of its proto-
pathic relative. The action of the alco-
hols and ethers on the cortex is surely by

Therapy 1 1 7

sedation, or what is the same thing, irrita-
tion and consequent exhaustion.

The fact that the active principle
of the leaf of one plant and that of limited
habitat, the erythroxylon coca, should
have the unusual power of sedation of
the sensory terminals, shows that the re-
sistance of these to the early sedative
power of alcohols and ethers is a protective
acquirement, the unfit having early per-
ished by intoxication.

Purely artificial products of the labora-
tory, such as the anilin derivatives, form
a class by themselves. Their only evo-
lutionary relations are by indirection
through their similarity with natural
products. Accordingly the known seda-
tives epicritic by preference are few ; that
is, the drugs with the function, useless in
nature, of soothing the cortex before
acting on the lower centres are antipyrin,
phenacetin, and other similar products
of the laboratory. The sulfonal group,
on the other hand, are first of all proto-
pathic sedatives. They are powerless to

n8 Insomnia and Nerve Strain

control processes of cognition, either
of nerve pain or genuine mental distress.
The vague activities that bring insomnia
and melancholy out of the subconscious
ego they may quiet, and this they do
first.

This leads to the final generalization
in regard to drug action. Drugs in so
far as they affect nerve tissue act on it
invariably by irritation, as do mechani-
cal agents. Some nerve tissues are
awakened to functional activity by such
action, in others that activity is impeded
by the irritation, this constituting so-
called sedative action. The difference
between stimulation and sedation is the
difference between closure of the circuit
and short-circuit.

This is not to say that either an internal
or external short circuit of a ganglionic
battery may not under some circum-
stances be beneficial. Its conditions of
usefulness are problems alike for the
pharmacologist and clinician.

COUNTER-IRRITANTS AND DIFFUSE

Therapy 119

IRRITANTS. — In treatment it should ever
be borne in mind that results are not
simply in quantitative proportion to the
nerve flow. Disaster, when not due to
an overwhelming quantitative loss,
usually comes from high-tension escape
from a single point, or escape at a point
where undesirable lines of least resistance
have been established.

High-tension escape may be controlled
or alleviated by ordinary counter-irrita-
tion or by diffuse irritation.

One of the most efficient means of
distributing irritation generally over the
protopathic terminals, thus lowering ten-
sion and diminishing loss at a special
point, is by the use of alcoholic drinks.
As alcohol produces at some times elation
and at other times depression, and the
tendency in psychic cases is to excess,
with consequent over-stimulation and
eventual visceral disaster, its use should
be discouraged as dangerous.

A safer method is by laxatives.
Protopathic intestinal activity tends in

120 Insomnia and Nerve Strain

general to euphoria, largely by the
elimination of irritant poisons.

If irritating, however, laxatives, like
other protopathic stimulants, quite rarely
produce melancholy instead of elation.

In case of either mania or melancholia,
in fact of any neuro-psychosis from a
local protopathic irritant outside the
gastro-intestinal tract, a laxative relieves
by the counter-irritant action of the
diversion of sensory nerve-currents. In
case of nervous symptoms from intes-
tinal stasis, laxatives relieve by removal
of the irritant poisons. These various
phenomena may in part account for the
well known clinical fact that purgation
is good for almost anything; it is in
fact the great protopathic regulator.

Purgation is, however, not available
indefinitely. Stomach and intestines fin-
ally rebel. The skin is a more patient
organ, and a seton may be efficient after
years of useful activity.

CLIMATE AND BATHS. — General stimula-
tion of the skin not only diminishes

Therapy 121

protopathic strain, it induces widespread
epicritic activity as well. Not only such
measures as hot and cold baths, the salt
glow, and the electric-light cabinet have
this effect, but a sojourn in some land
of sunshine keeps the skin stimulated,
especially if the clothing be light-colored.
This is an expedient to be used with
caution in cases of nerve strain. Tension
is taken off for a time by the continuous
flow of nerve currents in the skin, but
this relief is later succeeded by
exhaustion.

The diffuse nerve flow for a time
removes fatigue and gives a sense of
vigor, as does a salt rub or a hot bath.
Not under control like ordinary thera-
peutic measures, motor exhaustion and
sensory irritability are apt to ensue
in the neurotic and finally even in those
tolerably strong, with insomnia, which
may indeed be an early symptom.

In the tropics even more than in
sunny lands like Arizona, conditions favor
nerve flow, and with very different results.

122 Insomnia and Nerve Strain

For instance at Singapore where the
thermometer never goes above eighty-
five and the air is always near the dew-
point, with almost one hundred per cent.
of contained moisture, languor and ex-
haustion are so great that it is dangerous
to walk abroad in the middle of the day,
and sunstrokes are frequent. This differ-
ence from Arizona, where with a summer
heat of 1 10° or 1 1 5° sunstroke is unknown,
is striking. The clinical thermometer
does not show that in the drier climate
body heat is kept lower by evaporation.
Nerve waste, however, proceeds on very
different lines. The moist skin freely
taps the comparatively deep potential of
the blood stream through a skin con-
stantly soaked by the saline product of
the sweat glands.

The use of baths should be governed
by the capacity of the individual to
react. This depends on the integrity of
the vaso-motors, and this again largely
on the degree of their protection by fat.
In thin people undue contraction of the
vessels occurs, and vascular potential

Therapy 123

is rapidly lowered, with consequent
exhaustion.

SUGGESTIVE THERAPY. — In civilized
man the spoken word affects the
protopathic symptom powerfully for
both good and ill. Suggestive therapy
is usually powerless to affect a proto-
pathic system stimulated and attention
diverted by a severe physical irritant.
The wide application, however, and gen-
erally beneficial effect of this form of
treatment in its various modes of appli-
cation are well recognized in combating
the annoying and disabling symptoms
of the moderate cases.

Physical disorders lie especially open
to the action of faith and argument, and
the mysterious but familiar powers of an
extrinsic personality. Pain may be over-
come, confidence restored, vitality
stimulated.

The mentally afflicted, however, meet
persuasion with argument, they beat
down hope with despair, and in the worst
cases oppose to all psychic measures

124 Insomnia and Nerve Strain

the impenetrable defence of a soul with-
drawn and inaccessible.

INTENSIVE TREATMENT. — The maxi-
mum effect on disease is attained by
primary eradication of the cause and
simultaneous moral uplift and general
improvement of physique. The improve-
ment attained by one of these means
alone increases in geometric ratio with
the addition of the other two.

The most brilliant plan of treatment
in this wise is Dr. Weir Mitchell's rest
cure. By his device forced feeding
builds up the insulations of the brain
and cord and surrounds the terminals
of the skin and the subcutaneous vessels
with non-conducting fat. Massage and
electricity ensure enough discharge both
motor and sensory to keep nerve tension
low. Isolation prevents psychic shocks;
a cheerful nurse to read to the patient
and otherwise divert him prevents the
nerve-waste of fretting and homesickness,
and Dr. Mitchell's own patients have the
uplift of his commanding personality.

Predisposition and Heredity 125
PREDISPOSITION AND HEREDITY

PREDISPOSITION TO NERVOUS DISEASE.
— The neuropsychoses in general may be
defined as conditions of nerve waste from
excessive irritation, usually protopathic,
accompanied by phenomena of disor-
dered nerve action. The particular phe-
nomena are determined by lines of
original or acquired least resistance in the
nervous system and may be sensory,
motor, or psychic.

Neurotics are those in whom pro-
tective insulations have been more or less
weakened or broken down. The neurotic
tendency is constituted by original weak-
ness of protective insulations or acquired
abnormal activity on the part of the con-
necting glia.

So far as predisposition to the neuro-
psychoses is nervous, it manifests itself
in two ways; by unusual sensitiveness to
the action of irritants, shown by undue
sensory and emotional reaction; and by
unusual susceptibility to exhaustion from

i26 Insomnia and Nerve Strain

consequent overact ion. Patients in whom
the first kind of predisposition predomi-
nates are prone to mania, melancholia,
and various neuroses; those in addition
readily exhausted develop terminal de-
mentia or dementia precox.

Delicacy of emotional reaction can
hardly be considered degenerate. It is
in no sense atavistic, being conspicuously
absent in the lower races, and is rather a
mark of the finer adjustment to his
environment characteristic of civilized
man, than of a return to a lower and
coarser type.

There is another mode of nervous
reaction that may be considered degen-
erate, the reaction of too great resistance.
Robust persons may be nervously so
immune to toxins as to suffer corrosion
and sclerosis from suppurative or alco-
holic intoxicants, ending in death, with
no nervous reactions to indicate its
approach. A railroad with red lights
so delicately set as to flash out on the

Predisposition and Heredity 127

rumble of every passing cart might be
said to suffer from over-refinement in its
signal department. It would, however,
have advantages over a road with signals
still dark and the train in the ditch.

NEURO-PSYCHOSES NOT DEGENERATE.
— In the matter of the significance of the
so-called stigmata of degeneracy it is
interesting to study the countenances
of one's friends. There may be noted
among them the occasional irregular
teeth, slanting Mongolian eyes, asymmet-
ric faces, adherent ear-lobes, and all the
other signs and omens. Confront these
physical conditions with their mental
and moral qualities. The upright mind,
level head, kind heart, and playful de-
meanor are amply compatible with what
are called the physical attributes of de-
generacy. In the asylums note that
insanity is like sanity impartially dis-
tributed among people with and without
stigmata.

The idea suggests itself that a stigma

1 28 Insomnia and Nerve Strain

becomes important in the etiology of
insanity only when it is at once a stigma
and a lesion, as is the case with an im-
pacted tooth. This being granted, the
explanation of heredity of the neuro-
psychoses is at once in hand. They are
hereditary as headaches are hereditary,
never by the symptom but by the vis-
ceral lesion, the sagging kidneys, inactive
stomach, astigmatic eyes, crowded or
impacted or decayed teeth. The symp-
toms follow according to the pathologic
equation of the individual as headaches,
habit spasm, epilepsy, melancholy, mania,
or in presence of the tremendous irrita-
tion of impaction, even dementia precox.

Predisposition, then, to the neuro-
psychoses is of two kinds, nervous and
visceral. Nervous predisposition consists
in weakness or irregularity of the insulat-
ing tissues, or more often an overdevelop-
ment of glia cells with resulting abnormal
paths of communication, and may be
either hereditary or acquired. Visceral
predisposition consists in proneness to

Predisposition and Heredity 129

visceral disease, and may be either
hereditary or acquired.

There is a distinct value which may
attach to the materializing tendency of
the theory now advanced. Whatever
may be thought of the inner meaning of
the so-called physical stigmata, there is
another stigma adherent to insanity, the
odium of a disease that brutalizes and
that flows to posterity through the blood.
If it can be shown that this heredity is
not a slimy ancestral current descending
to engulf the soul, but something limited
and palpable, no worse a blemish than a
tumor or a gangrene, something will have
been done in the asylums for the comfort
of those who wait without the walls.

APPENDIX
DENTAL LESIONS

the viscera responsible for the more
obscure cases of nervous and men-
tal derangement I have no hesitation in
designating the teeth as the most import-
ant. This is not only on account of the
common, almost universal occurrence
of dental diseases, but because these
organs move, during the period of their
development, through the solid frame-
work of the jaw, highly innervated and
clothed by a membrane sensitive to
impact and to corrosive toxins.

The two most important lesions, im-
paction and abscess, are both of them in
some cases obvious to inspection, but
usually they can only be discovered by
skiagraph. Impactions may be in any
region of the jaw. They may be indi-
cated with some probability by a gap
131

132 Insomnia and Nerve Strain

where the missing tooth should be, but
such a gap is by no means conclusive.
An extraction may have been made and
forgotten, or teeth fail to develop, leav-
ing a gap or a temporary tooth persistent
sometimes for years.

The presence of all the teeth in their
proper place is not conclusive against
impaction, as is shown by an occasional
fourth molar.

Inspection is in many cases inadequate
to show abscess at the roots of a tooth.
In some cases the pus finds its way out
between the tooth and the gum, but ab-
scesses may persist for years, undermining
mental health or physical strength, with-
out pain or other localizing sign of their
presence.

The skiagraph is only capable of show-
ing absorption of bone, and pus may be
present for a time without this, but in
most cases within a few weeks or months
after development of an abscess the skia-
graph shows in the negative a dark area
of absorption. The germs find their way
to the roots of the tooth, usually through

CASE 2.— Insomnia. Alveolar CASE 4.— Melancholy. Alveolar

abscess. Lower molar tooth. abscess. First molar tooth. Roots
Roots partly absorbed. partly absorbed.

CASE 3. — Renal and Vascular Disease. Multiple
abscesses in both upper and lower jaws.

Case of Albuminuria with cardiac and vascular
symptoms. Complete nervous breakdown of five
years' standing Multiple abscesses in both upper
and lower jaws.

Appendix 133

the pulp chamber, as a result of decay, but
may be carried by material used in filling
the root canals. Abscess sometimes de-
velops, however, about a tooth dead
though not decayed.

A distinction should be made between
an alveolar abscess and an ulcerated tooth.
When an abscess at the root of a tooth
follows the peridental membrane to the
surface and involves the soft tissues, the
tooth is popularly said to be ulcerated.
This is a comparatively harmless process,
as pain and swelling make the difficulty
an obvious one. With the evacuation of
the pus the soft tissues recover but the
abscess remains in the bone, noxious but
inevident.

The object of dentistry is the conserva-
tion of the tooth, for mastication and
ornament. Dead teeth were formerly
filled, the main pulp chamber being
plugged and the roots left open. It was
found that abscess was practically invari-
able in the course of some years at the
roots of such teeth. Modern practice is

134 Insomnia and Nerve Strain

to fill dead teeth to the end of the roots,
as nearly as may be.

To estimate the proportion of success
and failure of this procedure it will be
necessary to consider in brief the course
of events in these cases. The process is
in effect a battle between the germs and
the blood. The germs, practically always
present in spite of the greatest care and
skill, march down the hollow of the tooth
by multiplication, often requiring sev-
eral years to cover the distance to the end.
Once out of the opening and in the jaw-
bone they are like a squad of soldiers with
their backs against a wall, the forces of
serum or white blood cell can only attack
in front, with an effectiveness dimin-
ished by half, and even if successful for
a time more germs are always lurking
in absolute safety in the dead tissue of
the tooth.

If to prevent this condition filling ma-
terial is pushed to the end of the root and
a little of it forced through into the jaw,
an irritant is in contact with the tissues,
and in most cases germs accompany it.

Appendix 135

If, on the other hand, it falls a thousandth
of an inch short of the opening, the tiny
germs find ample space for lodgment.

A man is as old as his arteries, and his
arteries are approximately as old as the
combined action of suppurative and
other toxins has made them in the preced-
ing years. Oral sepsis is not all super-
ficial. Its most important location is
usually deep in the jaws. In probably
no other part of the body can purely
irritative lesions be studied in contrast
with suppuration and toxemia and the
symptoms of each condition followed
with accuracy. Impactions result in pure
irritation, dental caries in irritation with
a minimum of toxemia; abscesses begin
in irritation, and result when large and
multiple in profound chronic intoxication.

The brilliant and rapidly developing
technique of dentistry has as its object
the preservation of the teeth for the
natural mechanics of mastication. " Ne
Varrachez pas" is the dental watch-word

136 Insomnia and Nerve Strain

in this country even more than in France.
The preservation of dead teeth is of
doubtful value. Suppuration may occur
about well filled teeth, and even about
teeth that are unfilled and undecayed. It
is almost inevitable about bad teeth, and
the one sure method of treatment is
extraction, which may, however, in many
cases be reserved until after the trial of
conservative measures.

The ominous conjunction of multiple
abscesses with the triad of cardiac,
renal, and vascular disease is one that has
been casually noted in several of the
cases reported in this series and some
others. To exclude suppuration as a
causative factor in these cases skiagraphs
are absolutely necessary.

Many other lesions are potent in
causing irritation. Fillings which en-
croach on the soft tissues or bone are
often revealed by the skiagraphs and so
remedied. I am unable as yet to give
any estimate of the importance of pulp

Appendix 137

nodules. It is only possible for me at
present to make the broad general state-
ment that irritation and septic poisoning
should be removed in every case, and
that local results of dental lesions are
trifling in comparison with their pro-
founder effect on general health.

In studying skiagraphs the original
negative should always be employed.
Much detail is lost in printing. The best
results in the diagnosis and treatment
of cases dependent wholly or in part on
dental disease are to be obtained only by
the co-operation of the physician and the
dentist. Skilful reading of skiagraphs
on the part of the physician is absolutely
necessary; all of the teeth in both jaws
must be shown to the ends of the roots.

I wish to express my thanks to Dr. C.
H. Clark, of the Cleveland State Hospital,
Dr. H. C. Eyman, of the Massillon State
Hospital, and Dr. George Stockton, of
the Columbus State Hospital, for their
courtesy in allowing me to observe the
patients under their care.

138 Insomnia and Nerve Strain

I am indebted to Doctors J. F. Stephan,
E. B. Lodge, and J. W. Van Doom for
much aid in dental matters. It need
hardly be added that the writer is alone
responsible for the opinions here set down.

THE TECHNIQUE OF DENTAL
SKIAGRAPHY

BY DR. E. BALLARD LODGE, CLEVELAND

PHE peculiar anatomical conditions of
the maxillae and the teeth render their
examination by Roentgen rays satisfac-
tory only when skiagraphs are taken by
placing the sensitive film or plate within
the oral cavity. A skiagraph taken through
the maxilla or the mandible with the plate
placed opposite causes not only a distor-
tion and lack of fine definition but also a
duplication of the shadows which render
the resulting picture vague and difficult
of interpretation. The writer's method
for obtaining skiagraphs of the teeth and
adjacent tissue is to make use of small
plates or films, preferably the latter,
protected from light and saliva as follows.
Two Seed's Process Films i J x ij inches
are wrapped in two folds of photographer's
139

140 Insomnia and Nerve Strain

black paper. The ends are turned to the
side opposite the chemical side of the
films and pasted down with a piece of
suitable paper. The films may now be
taken to the light without danger of
fogging. Next enclose the envelope in a
small aseptic napkin such as is made for
dental use, six inches square. This is to
prevent the corners of the envelope from
irritating the tissues. The ends are
folded away from the chemical side of the
film. Having done this, wrap the whole
in a small piece of dental rubber dam
five inches by two inches. This is
stretched and holds to the corners of the
package if tightly drawn. The rubber is
particularly necessary in taking lower
teeth to protect the films from moisture.
The package is now placed within the
mouth and in contact with the lingual
surfaces of the teeth, the patient being
directed to hold it in position by the
finger. It is important to place the
edge of the film parallel to the occlusal
or incisal alignment, and the chemical
side toward the ray.

Technique of Dental Skiagraphy 141

The adjustment of the tube varies for
different parts of the jaws. The ray
should always strike the film or plate
at right angles to a plane midway be-
tween the film and the teeth. In the
molar and bicuspid region of the upper
maxilla, the elevation of the tube with
reference to the teeth should be from
forty-five to fifty degrees above the hori-
zontal. In the incisor or cuspid region,
the tube may be somewhat higher than
this.

In the case of the lower molars and
bicuspids, the ray should be horizontal
so that it will strike the plate at right
angles, because in this instance it is
possible to place the film or plate parallel
with the long axes of the teeth. In case
the film is not held in a vertical position
but inclines away from the teeth at
its lower edge, it then becomes necessary
to lower the source of the ray or to elevate
the patient so that the ray emanates from
a point a few degrees below the horizontal,
to compensate for this deviation from a
parallel position.

142 Insomnia and Nerve Strain

With the lower incisors it becomes
necessary to direct the ray thirty to
forty-five degrees upward in order to get
a skiagraph that will not be greatly
distorted. This is because the film
cannot be placed with its lower edge
close to the teeth. The anode is placed
at an average distance of ten inches from
the teeth and the time of exposure is
about seven seconds.

Unless the angle of incidence of the ray
is carefully calculated, there is apt to be
either a foreshortening or an elongation
of the shadow.

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